Get Workers Compensation Quote Request Form

This guide will provide you with detailed instructions on how to effectively complete the Workers Compensation Quote Request Form online. By following these steps, you will ensure that your submission is accurate and helps you receive the most appropriate quote for your needs.

Follow the steps to complete the form online successfully.

1. Press the ‘Get Form’ button to access the Workers Compensation Quote Request Form and open it in your chosen online editor.
2. Indicate your preferred method of receiving the quote by checking either the Email or Fax option.
3. In the Client Information section, fill out your Company Name, Company Owner, and Federal ID#.
4. Specify your legal Entity type—whether it is a Sole Proprietor, Partnership, Corporation, or LLC.
5. Describe your operations clearly in the designated field to provide context for the quote.
6. Enter the Date Established and the Years of Experience in the relevant fields.
7. Provide your Mailing Address, including City, State, and Zip Code.
8. Fill in the Contact Name along with the Primary Phone Number and, optionally, an Alternate Phone Number or Fax Number.
9. Complete the Email Address field to ensure you receive correspondence regarding your quote.
10. Enter the Current Carrier, Renewal Date, and Premium details as applicable.
11. Specify the Location Address and indicate whether you are the Owner or Tenant.
12. If there are other Occupants, detail them in the space provided.
13. Choose the Limits for your coverage from the available options.
14. Complete the Payroll and Number of Employees fields under the Property Information section.
15. If applicable, list the names and titles of any Owners or Officers under the Workers’ Comp Owners/Officers Coverage section.
16. Indicate if you would like to include any Claims from the past three years.
17. Use the Additional Information section to provide any other relevant details that may aid in processing your request.
18. If you are working with an agent, enter their name in the designated field.
19. Once all sections are filled out, you can save your changes, download, print, or share the form as needed.

Begin filling out your Workers Compensation Quote Request Form online today!