*(Workers compensation class codes can be found on the declaration page of your workers compensation policy...if a new business, describe the duties of your employees) **The quote you receive will be contingent on satisfactory workers compensation information/loss runs and/or satisfactory loss control visit. By choosing yes here and CLICKING the SUBMIT BUTTON BELOW YOU AGREE TO THE FOLLOWING STATEMENT. To the best of my knowledge, I represent that all answers and statements of this form are complete and true. Misrepresentations or misstatements may result in termination of contract.
Company Name
Contact Person
Address
City, State
Zip
Phone #
Email Address
Type of Business
Payroll Cycle
Number of Locations
Workers Comp Class Code, State, # of Employees, Annual Payroll
Do you have a workers compensation claim/loss problem?
Do you have copies, or can you get copies, of your most recently evaluated workers compensation loss runs?
Online Quote Form
6302 Manatee Ave W, Suite K. Bradenton, FL 34209 | Ph: (941) 761-7704 | Fax: (941) 761-7706
