Request a QuoteTo request a proposal please fill out the form below.All fields are required Complete Name of Company*Company Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Contact*Detailed Company Description*Tax ID Number*Type of Business*--Please Select--Sole Proprietor (1040 Schedule C)Corporation (1120)Partnership (1065)S-Corporation (1120S)Trust (1041)Non-Profit Organization (990)How Long in Business?*Company OwnersOwner 1Please provide information for all company owners.Name* First Middle Last Percent Ownership*Please enter a number from 1 to 100.Work Comp Insurance CoveredW/C Class*Annual Salary*Owner 2Please provide information for all company owners.Name First Middle Last Percent OwnershipPlease enter a number from 1 to 100.Work Comp Insurance CoveredW/C ClassAnnual SalaryOwner 3Please provide information for all company owners.Name First Middle Last Percent OwnershipPlease enter a number from 1 to 100.Work Comp Insurance CoveredW/C ClassAnnual SalaryOwner 4Please provide information for all company owners.Name First Middle Last Percent OwnershipPlease enter a number from 1 to 100.Work Comp Insurance CoveredW/C ClassAnnual SalaryOwner 5Please provide information for all company owners.Name First Middle Last Percent OwnershipPlease enter a number from 1 to 100.Work Comp Insurance CoveredW/C ClassAnnual SalaryBreakdown of Payroll by Workers' Compensation Codes:The first box contains an example and should be used as a reference. Click in the box and enter your number.W/C Class*# of Employees*Ann. Gross Payroll*Email* Phone*Available Documentation Current Workers' Compensation Carrier and copy of Declaration page (showing annual renewal date and experience modifier) Copy of most recent medical insurance invoice (showing employees covered, dependents, and rates. Ages or birth dates if available)Place a check in the box if the following documentation is available.If electronic, please attach your documentation to this form. Drop files here or CAPTCHA
