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info@allchoiceinsurance.com
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844.540.0463
Workers Compensation Insurance Quote
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WHAT IS IMPORTANT TO YOU?
(Other Than Price) What Is Most Important When It Comes To Choosing An Insurance Carrier?
*
Claims Service
Financial Rating
Steady Pricing (Limited Price Spikes Up Or Down)
(Other Than Price) What Is Most Important When It Comes To Choosing An Insurance Advisor?
*
An Advisor That Will Educate Me About My Coverages & Offer Advice
Positive Reviews (ex Google Review)
Anywhere Access (Online, Text, Phone, etc)
Access To Multiple Insurance Carriers
Quick Turnaround On Service Requests
INSURED | CONTACT INFORMATION
Business Name
*
Primary Business Contact
*
First
Last
Mailing Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Indiana
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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North Carolina
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Northern Mariana Islands
Ohio
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Puerto Rico
Rhode Island
South Carolina
South Dakota
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Texas
Utah
U.S. Virgin Islands
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Virginia
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West Virginia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mobile Phone
*
Is It Ok To Text You?
*
Yes
No
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
*
Apartments
Condo / Homeowner Association
Contractor (Construction)
Landlord (Rental Unit Owner)
Lessors Risk (Commercial Property Owner)
Manufacturing
Office
Professional
Restaurant
Retail
Service
Wholesale
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
MM slash DD slash YYYY
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
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Max. file size: 50 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.
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