Worker’s Compensation Insurance Quote Request Worker's Compensation Insurance Quote Request For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.Personal InformationSelect Your StatePlease Note: We only write insurance for these states.SelectNew HampshireVermontAddressWhat is your address? Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name*What is your name? First Last Telephone Number (Day)*What is your business telepone number?Telephone Number (Night)What is your home telepone number?Best Time to CallWhat is the best time to call? : AM PM AM/PM Email Address*What is your email address? FaxWhat is your fax number? Underwriting InformationNature of BusinessWhat is the nature of your business?Is the business a corporation, partnership or sole proprietorship? Corporation Partnership Sole Proprietorship Number of OwnersHow many owners?Please enter a number greater than or equal to 0.Number of EmployeesHow many EmployeesPlease enter a number greater than or equal to 0.Payroll of ownersWhat is the payroll amount of the owners? Payroll of employeesWhat is the payroll amount of the employees? Total Annual Gross ReceiptsWhat is the total annual gross? Business License NumberWhat is the business license number? License TypeWhat is the license type? Years of ExperienceYears of experience in this business?Please enter a number greater than or equal to 0.Years Operated Under Current NameHow many years have you operated under your current business name?Please enter a number greater than or equal to 0.Other Business NamesHave you used any other business names during the past 5 years? Yes No Open 24 hoursIs this business open 24 hours a day? Yes No Deep FryingAny deep frying (food)? Yes No ManufacturingIs there any manufacturing, mixing, re-labeling or repackaging of products? Yes No Propane Tank FillingIs there filling of propane tanks? Yes No Unusual ExposuresPlease describe the nature of your business and ANY unusual exposures.Payroll Detail InformationEmployee Groups*Class/CodePayroll RateAnnual Payroll Claims InformationWere there any losses or claims in the last 5 years?Losses - Claims Yes No What is the date, amount paid and description of each loss or claim?Coverage InformationWhat is the current insurance company? Amount Current CoverageHow much are you paying now? Liability LimitWhat is the liability limit requested?Select$100,000$300,000$500,000$1,000,000Building LimitWhat is the building limit requested? Questions, Comments or Additional CoverageQuestions, Comments or Additional CoverageAre there any questions, comments or additional coverage required?CaptchaPLEASE NOTE: Insurance coverage cannot be bound without a written binder from our office Print Form