Assurance Agency, Inc.    

 
WORKERS
COMPENSATION
QUOTE		   We would like to provide you with a free, no-obligation workers compensation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
 

Company Information
 Name:
 Company Name:
Address: 
City:   State:   Zip:
Day Phone:   Fax:
Best Time To Call:   AM   PM
Email Address:
Federal ID Number:   Years in Business:
Individual   Partnership   Corporation


Business Description
Please provide type of business and complete description of operations.


Class Code & Payroll Information
Total estimated annual payroll for each type of worker. (There will be a breakdown by the classification on your prior policy.)
Class Code:   Description: Payroll: $
Class Code:   Description: Payroll: $
Class Code:   Description: Payroll: $
Class Code:   Description: Payroll: $
Class Code:   Description: Payroll: $


Current Workers Compensation Insurance Information
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
Employer Liability Limit: $  
Current Year Experience Modifier:  


Claims Information
Please list all workers compensation claims within the prior 5 years and give basic details for the accident including the amount paid.


Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.