Workers Compensation Insurance Quote Form in West Islip, New York

632 Union Boulevard
West Islip, New York 11795
Phone (631) 669-6200
Fax (631) 669-2349

Our commitment is to serve you with the highest degree of professionalism. You can expect our associates to utilize their extensive knowledge and experience to act as your personal insurance advisors. Our formula for success is quite simple - We work for you.

Thank you for your trust in us,

Dan Weber, President

Workers Compensation Insurance Quote Form

First & Last Name:
Street Address:
City, State & Zip:		,
E-Mail Address:
Telephone:		Fax:
Current Insurance Information
Insurance Company Name:
Any losses in last 3 years?:
No. of claims:		Claim amt. pd:
Premium Amount:		Policy Exp. Date:
MOD Factor:		Policy No.:
Describe the type of Coverage you currently have:
Prior Carrier Info
Insurance Company Name:
No. of claims:		Claim amt. pd :
Premium Amount:		How many years with:
MOD Factor:		Policy No.:
About Your Business
No. of Full-time:		No. of Part-time:
Owner's Name:		Fed Tax ID:
License Type:		Yrs in Business:
License No.:		No. of locations:
Annual Gross Sales:		Square Footage:
Est payroll / mo.:		Type of Business:
Please describe your business here:
Owners / Partner / Officers
Name	Date of Birth	Title	Ownership Percent



Payroll Information
Class Codes	Employee Duties	Annual Payroll	Hourly Wage




General Information
Do you offer safety programs?
Do offer health benefits to majority of employees?
Do employ any minors (under 18)?
Is operation all/part of existing business that was purchased/acq.?
Do you use subcontractors?
Use any equipment that bends/shapes/forms?
Are athletic teams sponsored?
Been a lapse in coverage during past 12 months?
Any work above 15 feet?
Had a bankruptcy in past 7 years?
Are a member of any trade organizations?
Additional Information: Please provide any additional information that may be helpful in giving you an accurate quote or that you didn't have enough room for.

Workers Compensation Insurance Quote Form

Current Insurance Information

Prior Carrier Info

About Your Business

Owners / Partner / Officers

Payroll Information

General Information