Workers Compensation Only
Quote Request Form

Information needed to quote Florida Workers' Comp. Insurance!.
Please complete all blanks. In addition, please fax 3 years loss runs and a copy of your current Declarations page to 561-748-6785.

If you do not have coverage at this time please call 561-575-5187.
Client Information
   
Your Name:
Company Name:
Address:
Telephone:
E-mail Address:
Best time to Call:
Years in Business :
Company Structure : Indiv. Corp. Partnership
Taxpayer ID#:
License #:
Number of Employees:
Annual Payroll:
Current Carrier:
Expiration Date:
Exp. Modification %:
Detailed description of operations:
     
Class Code Job Description Payroll for this Code
     
Claim Information
Number of claims last 3 years:
Amount paid:
Please give complete details, including dates:
Please fax 3 years current loss runs to 561-748-6785
Miscellaneous Information
     
  Yes No
Any lapse in coverage during last 3 years?
Any work performed underground or above 15 feet?
Does owner/manager have at least 3 years experience in the trade?
Any work performed on barges, vessels, docks, bridge over water?
Any work subcontracted without certificates of insurance?
Is a formal safety program in operation?
Any prior coverage declined/canceled/non-renewed last 3 years?
Any employee-leasing or labor exchange of any kind?
     
Please give details to "all yes answers" and/or other information:
  Send product literature
  Send company literature
  Have a salesperson contact me
Your Message:
 
Please be sure that all questions are answered before you press "Send".
We are unable to respond to requests with incomplete information. If you prefer, print the form and fax it to 561-748-6785.
Design by: Phoenix Internet        Copyright © Mr. Workers Comp 2005-2006