QUOTE WORKERS COMP

Company Name *

Legal Entity *

Partners / Owners *

Years In Business *

Tax ID (FEI 9 digits)

Annual Revenue (format xxxx.xx) *

Sub-Contractors *

Approximately what percentage is subcontracted?

If yes, do you obtain Certificates of Insurance list your compnay as additionally insured?

Do you currently use a payroll leasing company? *

Number of Employees *

Annual Payroll (format xxxx.xx) *

Select job that describes majority of employees. *

If NOT LISTED, please enter brief description of employee job description.

Do any of your employees travel out of state? *

Currently Insured? *

Expiration Date +

Upload a copy of your existing policy decs page

Please select box (es) of commercial insurance that you would like quotes for. If you are unsure as to what the insurance covers, please click on blue question mark icon for a brief description.

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Commercial Auto (including light & heavy trucks)

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Commercial Property

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General Liability

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Professional Liability (E&O)

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Directors & Officers Liability

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Business Owners Package Policy (BOP)

First Name *

Last Name *

Address *

City *

State *

Zip *

County *

Phone *

Email Address *