Worker's Compensation Insurance Quote Request

Please complete the following information to start an work comp insurance quote.

* Required

Contact Information

First Name *

Last Name *

Email Address *

Company Name *

Company Website

Contact Phone Number *

Business Address

City

State *
Texas
Other

Zipcode *

Best Method of Contact *
Phone
Email
Either Phone or Email

Business Information

Type of Business *
Individual
Partnership
Limited Liability Corp.
Corporation
Other

IndividualPartnershipLimited Liability Corp.CorporationOther

Year Business Started *

Business experience for principal
New Business Owner
One Year Prior Experience
Two Years Prior Experience
3-5 Years Prior Experience
Over 5 Years

Description of Business

Business FEIN (Federal Employer ID number)

Work Comp Quote Information

Work Comp Classification & Payroll for each occupational class (just supply what you know)

Work Comp for Owners?
Owners Included
Owners Excluded

Employer's Liability Limit Needed
minimum
$500 thousand
$1 million
more than $1 million

States in which business has locations / employees

Prior Worker Injury Claims (past 5 years) *
None
One or more claims (please list below)

Please list prior worker injury claims (if any). Please include date, amount paid and cause of injury

Insurance Needed in Addition to Work comp(mark any that apply)
Businessowners
Business Auto
Business Property
General Liability
Product Liability
Professional Liability
Other (please specify)

Details on Other Insurance Needed (Limits, etc.)

Current Insurance Company
Allstate
CNA
Farmers
State Farm
Texas Mutual
Travellers
Other
None

Reason for Insurance
Jobsite or Contract Requirement
State Regulatory Requirement
Protection of Business & Owners
Business Plan
Competitive Bid
Other

Enter Word Verification in box below *

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