Workers Comp Quote
Please fill out the following to receive a workers compensation quote.
Business Name *
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Business Phone Number *
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Business Location Address *
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Business Mailing Address *
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FEIN Number *
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Business Type (Corp, LLC, etc.) *
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Description of Operations *
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Year Business Started *
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Prior Insurance Carrier (put none if none) *
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# of Employees *
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Owner Names and % of Ownership *
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Do Owners Want to be Covered on Workers Compensation? *
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Class Code 1 Description ( Clerical, excavation, plumbing, etc.) *
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Class Code 1 Payroll *
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Class Code 2 Description
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Class Code 2 Payroll
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Class Code 3 Description
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Class Code 3 Payroll
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Class Code 4 Description
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Class Code 4 Payroll
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Comments
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This form was created inside of Main Street Insurance Agency.