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Workers Compensation Quote
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Indicates required field
Name
*
First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
*
Phone Number
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Cell Phone
*
Website
*
Number of Owners
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If more than 1 owner or officer is to be excluded, list each name, title and date of birth in the comment section below.
Exclude Owner
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Yes
No
Do you want to exclude the owners from coverage? If YES, We will not count their payroll in calculating premiums.
Owners Name
*
Date of Birth
*
Employer Identification Number
*
We are unable to offer a work comp quote without your Employer Identification Number (EIN) or if you are operating as an individual and do not have an EIN, enter your social security number as the EIN.
Describe your operation
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Class Code 1
*
If Known enter class code
Class Code 2
*
If Known enter class code
Class Code 3
*
If Known enter class code
Payroll Class Code 1
*
Enter annual payroll for class code 1
Payroll Class Code 2
*
Enter annual payroll for class code 2
Payroll Class Code 3
*
Enter annual payroll for class code 3
Currently Insured
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Yes
No
Prior Insurance Company Name
*
Enter name of your prior insurance company and expiration date if previously insurance
Prior claims or losses
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No Prior Claims
Yes Prior Claims
Notes Section
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Upload File
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Max file size: 20MB
You can upload prior declaration page or loss runs from your previous company here.
Submit
