Workers Compensation Insurance Quote

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PRODUCER

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LEAD SOURCE

INSURED | CONTACT INFORMATION

Business Name*

Primary Business Contact*

First Last

Mailing Address*

Street Address City State ZIP Code

Mobile Phone*

Is It Ok To Text You?*

Email*

BUSINESS INFORMATION

Federal ID*

# Of Full-Time Employees*

Enter "0" if No Full-Time Employees

# Of Part-Time Employees*

Enter "0" if No Part-Time Employees

Annual Revenue (Gross Sales)*

Annual Payroll*

0 Employees = $0 Payroll

Nature Of Business*

Date Business Started*

Description Of Primary Operations*

INSURANCE HISTORY

Workers Compensation - 5 Year Loss History*

No Losses
Losses

Has Your Workers Compensation Insurance Ever Been Cancelled*

Never Had Workers Compensation
No
Yes - Non-Payment
Yes - Claims
Yes - Underwriting Reasons
Yes - Other

Workers Compensation Information

Effective Date

Current Coverage

Yes
No

Current Carrier

Number Of Class Codes

1
2
3

Class Code (Main)

If you don't have/know the Code - please enter description

Class Code Payroll (Main)

Class Code (2)

If you don't have/know the Code - please enter description

Class Code Payroll (2)

Class Code (3)

If you don't have/know the Code - please enter description

Class Code Payroll (3)

Workers Compensation Coverage Information

Workers Compensation Limit

$1,000,000 | $1,000,000 | $1,000,000
$500,000 | $500,000 | $500,000
$100,000 | $500,000 | $100,000

Enter Misc Workers Compensation Information

Upload Misc Workers Compensation Files

Drop files here or

Max. file size: 60 MB.

Disclosure Statement

By submitting this request, you agree to receive communication(s) from ALLCHOICE, Inc. via Phone, Text, SMS, Email, Voicemail, or any other form of communication that may be deemed as beneficial.

We use the information you provide as well as information from other sources, such as your driving record, claims, and credit histories, to calculate a price for your insurance.