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Workers Compensation Form

In order to receive preliminary insurance and initial quote information please fill and send in the following form. Thank you!


NAME / DBA


Sole Proprietor
Partnership
Corporation

BUSINESS MAILING ADDRESS

CITY STATE ZIP

BUSINESS TYPE or CLASSIFICATION or SIC CODE

EXPERIENCE MODIFICATION FACTOR

DO YOU CURRENTLY HAVE INSURANCE?
Yes
No

EXPIRATION DATE MM/DD/YYYY / /

LOSS HISTORY (last 3 years)

 


General Comments / Additional Questions

How did you first discover or learn about us?

Please contact me by:

Email


Phone
If you'd like to be contacted by phone, please indicate the best time for us to call. BETWEEN


Fax


Mail Address

Thank you for your time! - Plaza Insurance Sales, Inc.