Quote Workers Compensation

Workers Comensation Insurance Questionnaire for all types of Contractors/Artisians

Coverage nor Endorsement requests cannot and will not be bound by use of this or any other quote form on this site.

Are you ready to proceed?

Yes

No

Thank you for your consideration. When you are ready or need our assistance we will be here for you. Have a good day.

As a reminder, We write with insurance carriers that write National and Global Accounts. Thank you for your consideration. Have a nice day.

Basic Business Information

Business Name

Position

Your First and Last Name

Phone

Email

Select Your Business Entity Type

FEIN / SS

Locations - Click the "Add Entry" Button

Configuration Required
Use the Nested Form and Summary Fields settings to choose the form and fields to display in this Nested Form field.

Desired Effective Date

We require at least 5 days lead time to present a quote. Coverage is not bound in our presenting a quote.

Date

CONTACT INFORMATION

Inspection

Name

Phone

E-Mail

Accounting

Name

Phone

E-Mail

Claims

Name

Phone

E-Mail

INDIVIDUALS TO BE INCLUDED OR EXCLUDED

Full Name & Date of Birth

Title & Percent Owner

Duties

Include/Exclude?

iNCLUDE/EXCLUDE

Configuration Required
Use the Nested Form and Summary Fields settings to choose the form and fields to display in this Nested Form field.

For "included" Employees Enter Class Codes and estimated/projected annual payroll

Configuration Required
Use the Nested Form and Summary Fields settings to choose the form and fields to display in this Nested Form field.