Quotes for Florida Workers' Compensation Insurance | FloridaWC.com | Florida Workers' Compensation Insurance Broker Providing Workers Comp Information and Premium Indications to Florida Businesses

General Information:

Business name:
Your first name:	Your last name:
Title:	Daytime phone #:
Fax #:	Cell phone #:
Email:
Mailing address:
Mailing address line 2:
City, State:	Zip Code:

Please describe the nature of your business:

Payroll breakdown by employee classifications:

Job Description

Number of Employees

Estimated
Annual
Payroll

Job 1:
Job 2:
Job 3:
Job 4:
Job 5:

Previous workers' compensation information:

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:	Policy # :
Have you had any workers' comp claims in the last 3 years? Yes No

If yes, please describe here:

Talk to us

Thank you for visiting our website, FloridaWC.com*, and for taking the time to complete our quote request forms. After submitting the form to the left, you can expect an email reply or phone call within 1 business day; if you need immediate assistance or would like to call our office, please contact us at:

1-866-990-COMP (2667)

Fax: 1-866-991-COMP (2667)

*FloridaWC.com is a website provided by Black Bear Insurance Agency.

General Information:

Please describe the nature of your business:

Payroll breakdown by employee classifications:

Previous workers' compensation information:

Talk to us

1-866-990-COMP (2667)

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