FloridaWC Quotes

Contact Information

Business Name:

Your Name:

Your Title/Position:

Business Phone:

Cell Number:

Your Email:

Mailing Address:

Mailing Address Line 2:

City:

State:

Zip Code:

Please describe the nature of your business:

What type of legal entity is your business?

IndividualPartnershipCorporationLLC

What is your business Tax ID Number (FEIN)?

What year was your business established?

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:

Do you currently have workers comp coverage in force?

YesNo

Are you currently under cancellation for any reason?

YesNo

Current expiration date:

Have you had any workers comp claims in the last 3 years?

YesNo

If yes, please describe here: