Workers Comp Quote Form

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? IndividualPartnershipCorporationLLC
What is your business Tax ID Number (FEIN)?
What year was your business established?
How many years of experience do you have in this industry?
Do your employees travel outside the state of Florida? YesNo
How did you hear about FloridaWC? Search EngineAdvertisementReferralMailerOther

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? YesNo
Are you currently under cancellation for any reason? YesNo
Current insurance company (not agency):
Current expiration date:
Policy #:
Have you had any workers comp claims in the last 3 years? YesNo
If yes, please describe here: