APPLY FOR WORKERS COMP QUOTES WITHOUT THE HASSLE
We have you Covered

ONLINE WORKERS COMPENSATION QUOTE APPLICATION

We make it quick & easy to secure the lowest workers' compensation insurance quotes on the market. Simply complete the online Quote Application below and receive quote indications in as little as same day!

GENERAL:

* Indicates required field

Company Name *

Phone Number *

Website *

What year was your business established? *

What is the legal structure of your company? *

Applicant Name *

First

Last

Email *

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

PAYROLL:

On average, how many part time employees will your business have over the next 12 months? *

On average, how many full time employees will your business have over the next 12 months? *

Please provide your estimated annual payroll for each workers' compensation insurance class code.
(if you do not know the class code, you can simply describe the type of work, i.e. clerical, sales, carpenter, barber, etc.)

Class Code/Job Description *

Estimated Annual Payroll *

WORKERS COMP HISTORY:

What date do you want coverage to start (effective date)? MM/DD/YYYY *

Does your business currently have workers' compensation insurance? *

Yes No

How long has your business continuously had workers' compensation insurance? *

How many workers' compensation claims has your business had in the past 3 years? *

Submit

APPLY FOR WORKERS COMP QUOTES WITHOUT THE HASSLEWe have you Covered

ONLINE WORKERS COMPENSATION QUOTE APPLICATION

GENERAL:

PAYROLL:

WORKERS COMP HISTORY:

APPLY FOR WORKERS COMP QUOTES WITHOUT THE HASSLE
We have you Covered