Worker’s Compensation

Protect one of your business' most valuable assets by securing Workers Compensation insurance. With this insurance, your people are protected financially in the event of illnesses, diseases, injuries and disability incurred while at the workplace.

Workers Compensation Insurance pays for medical care and physical rehabilitation of injured workers and helps to replace lost wages while they are unable to work. It may also provide benefits for dependents of those workers who are killed because of work-related accidents or illnesses.

We are uniquely positioned to provide workers comp solutions by the unmatched financial strength and expertise of the markets available. Each of our carriers provides an area of expertise in their targeted industry.


Your insurance should start on?:
E-mail:*
Phone:*
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Address:*


Full Name:*
DOB:
Fax:*
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Comments:

Company Information

Company Address:*
Annual Gross $:
Building Type:
Type of Business:
Please describe your Business:



# of Full-time:
# of Part-time:
# of Locations:
Yrs. Business:
Yr. Build:
Sprinklered:
Square Footage:
Owned Autos:
Estimate Monthly Payroll:
Losses in the last 3 years:

Current Carrier Information

Carrier:
Premium Amount:
Claim amount paid:
Losses in the last 3years



How many years with:
MOD Factor:

Owners / Partner / Officers

Name:
Title



Ownership %

Payroll Information

Class Code:
Employee Duties:



Annual Payroll:
Hourly Wage:



MODFactor:
Word Verification:

Please Read

By completing and submitting a form, you agree that no coverage is bound, no policy is in effect and no changes are made until you are contacted by one of our representatives. All information submitted will only be used for the purpose of completing your request to explore insurance opportunities.