Worker's compensation Insurance Quote Request We offer all types of insurance coverage for your business. Fill out the form below to get started on a worker’s comp insurance quote. Worker's Comp Insurance Quote Form Name (required) Email (required) Phone Address Business Name Type of Business Type of Company CorporationSole ProprietorPartnership How did you hear about us? Are you currently insured? YesNo If yes, why are you considering changing? Name of current insurance company Annual Premium Effective Date of Coverage Five years of loss runs Any losses in the last 5 years? Can your company fax us a copy of your current declarations page? Number of employees Classification and code number (if known) Annual payroll per class (or total payroll) Does the owner or corporate officers want to be covered? Years in business? Years experience? NYS Disability How many full time male employees? How many part time male employees (<30 hours)? How many full time female employees? How many full time female employees (<30 hours)? When do you need the quote by? Comments Supporting Documents Attach a copy of your existing insurance policy. Supporting Documents