Workers Compensation Back To BUSINESS INSURANCE Please provide the following information to obtain a quote Please remember, that no coverage should ever be considered bound until you have received confirmation from our office. What is the name of your business:* What is the address of your business:* Please describe your business:* Federal ID number:* Describe the entity of your business:* Sole proprietorPartnershipCorporationNon-for-profit organizationOther Click here if you answered "Other" to the above question: If other, please describe Please provide information about your employees 4-digit classification code:* If you are not sure what this is, leave blank Description of classification code:* This is basically a description of the type of job that this group of employees performs - example: "clerical" What state are the employees in this classification in:* How many full-time employees do you have in this classification:* How many part-time employees do you have in this classification:* What is the estimated annual payroll that you will have for this classification:* $ Please provide information about your workers' compensation experience/coverage information Do you have an experience modifier applied to your company:* YesNo Click here if you answered "Yes" to the above question: If so, what is the modifier Would you like the payroll for the owner, partners, or principals included or excluded:* IncludedExcluded Click here if you answered "excluded" to the above question: Indicate the classification and payroll amount for the excluded officers Describe any claims that you have experienced in the past five years:* Do you have payroll in states other than the state your business is domiciled in:* YesNo Click here if you answered "Yes" to the above question: If other, please describe Please provide us your contact information in order to complete this quote form What is the contact name:* Email address:* Phone number:* What type of phone number is this:* Office/workHomeMobile What is the best time to contact you:* How did you hear about us:* I am a current customerA friendInternet search engineNewspaperOtherEmployee Comments or additional information Did You Know Fences are not included in most property policies without being separately scheduled. Would you like someone to contact you about this:* YesNo Thanks for providing this information. If we need to contact you for additional information, we will send you a message through the secure Message Center found in File Cabinet. You can view a copy of this request, and a copy of your ID card, by clicking on File Cabinet. You will receive an email confirming this request made. By clicking the Submit Button you are agreeing to the Terms Conditions of doing business with our agency via the Internet. Click here to view the Terms & Conditions.