Workers Compensation Program
REQUEST FOR QUOTE
Business Legal Name:
Contact Name:
Business Address:
City / State / Zip:
Business Phone:
Fax #:
Email:
Website:
Type of Business:
Years In Business:
Current Workers Compensation
Insurance Company:
Estimated Annual Premium Currently Being Paid:
Experience Modification (E-Mod):
Renewal Date:
Number of Employees:
Current Workers Compensation Policy:
Class Code
Description of Duties
Estimated Annual Payroll
Please call Kristy Roberts at (702) 648.6887 if you have any questions, or would like to discuss your workers compensation insurance.
Please be aware that completing this document does Not constitute an insurance contract. No coverage can be bound until approved by Employers Insurance Company. Because your privacy is important to us, we want you to know that your information will be only be used for the purpose for quoting, issuing and maintaining insurance coverage(s).
Legal Disclaimer
:
Privacy Policy
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KTG
