FloridaWC
Workers Comp Quote Form
Contact Information
Business Name:
Your Name:
Your Title/Position:
Business Phone:
Cell Number:
Your Email:
Mailing Address:
Mailing Address Line 2:
City:
State:
FL
AK
AL
AR
AZ
CA
CO
CT
DE
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
ME
MD
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WI
WV
WY
Zip Code:
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?
Payroll Classifications
Job 1 Class Code / Description:
Job 1 # of Employees:
Job 1 Annual Payroll:
Job 2 Class Code / Description:
Job 2 # of Employees:
Job 2 Annual Payroll:
Workers Comp Insurance
Do you currently have workers comp coverage in force?
Yes
No
Are you currently under cancellation for any reason?
Yes
No
Current expiration date:
Have you had any workers comp claims in the last 3 years?
Yes
No
If yes, please describe here:
Please leave this field empty.