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Workers Comp Quote

General Contact Information

Business Name:
Your Name:
Your Title/Position:
Contact Phone Numbers:
Your Email:
Mailing Address:
Mailing Address Line 2:
City, State, Zip:

Business Details

Please describe the nature of your business:
What type of legal entity is your business?  Individual Partnership Corporation LLC
What is your business Tax ID Number (FEIN)?
What year was your business established?
Do your employees travel outside the state of Florida?  Yes No

Payroll Breakdown by Employee Classifications

Classification Code
or Job DecriptionNumber of EmployeesEstimated Annual Payroll
Job 1:
Job 2:
Job 3:
Job 4:
Job 5:

Workers Comp Insurance Background

Do you currently have workers comp coverage in force?  Yes No
Are you currently under cancellation for any reason?  Yes No
Current insurance company (not agency):
Current expiration date:
Have you had any workers comp claims in the last 3 years?  Yes No
If yes, please describe here: