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