Workers’ Comp Request a Quote “*” indicates required fields 1Required Information2Additional Information Basic InformationLegal Name of Business*Federal TaxID Number*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Business/Description of Operations*Contact Name*Contact Phone Number*Contact E-Mail* Best Time to Call Hours : Minutes AM PM AM/PM Referring Payroll CompanyPayroll Company Name*Payroll Rep Name*Phone*E-mail* This Company is Existing Client Prospect Payroll FrequencyPlease Select…WeeklyBi-WeeklySemi-MonthlyMonthlyFirst Check Date MM slash DD slash YYYY Company InformationEntity TypePlease Select…CorporationPartnerIndividual/Sole ProprietorLLCLLPOtherYears in BusinessAdditional Locations Add RemoveWorkers’ Compensation InformationCurrent Insurance Company (not agency)Annual Premium AmountPolicy Effective Date MM slash DD slash YYYY Policy Expiration Date MM slash DD slash YYYY Class CodesClass Codes or Description of JobStateEstimated Annual PayrollNumber of Employees in Class Code Add RemoveHave there been Injuries or Losses in the Last 4 Years? Yes No
