FloridaWC
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:
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
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?
How many years of experience do you have in this industry?
Do your employees travel outside the state of Florida?
Yes
No
How did you hear about FloridaWC?
Search Engine
Advertisement
Referral
Mailer
Other
Payroll Breakdown by Employee Classifications
Classification Code
or Job Decription
Number of Employees
Estimated 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:
Policy #:
Have you had any workers comp claims in the last 3 years?
Yes
No
If yes, please describe here:
Please leave this field empty.