It's the Law... Are you covered? Unsure if Workers Compensation Insurance applies to you? Click here to find out.

Quote submittal form

Please complete the following to receive your cost free quote:

Name of business:

Address:

City:

State:

Zip:

Contact Phone:

Contact Email*:

Total # of employees to be covered:

Breakdown of employees / people covered:

Owners/ partners:

Full- time employees:

Part- time employees:

Sub- contractors:

Type of business:

Years in business:

Do you currently have a workers comp policy: Yes No

If yes complete the following:

Current provider:

Expiration date:

Any workers comp claims in the past 5 years? Yes No

Annual Gross Payroll: