Workers Comp Quote

Please take a moment and tell us about yourself

Business Name(*)
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First Name(*)
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Last Name(*)
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Contact Phone Number(*)
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Cell Number
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Email Address(*)
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Mailing Address
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Mailing Address Line 2
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City
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state
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Zipcode
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Please describe the nature of your business
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What type of legal entity is your business?

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What is your business Tax ID Number (FEIN)?
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What year was your business established?
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Do your employees travel outside the state of Florida?

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Payroll Breakdown by Employee Classifications

Classification Code or Job Description of a Recent Project
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Number of Employees
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Estimated Annual Payroll
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Do you currently have workers comp coverage in force?

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Are you currently under cancellation for any reason?

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Current insurance company (not agency)
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Current expiration date

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

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If yes, please describe here:
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