WORKERS COMPENSATION MADE EASY!

Please answer the questions below so we can lower your work comp premiums!

1. Company Name *This question is required.

2. Contact person *This question is required.

3. Contact Email This question requires a valid email address.

4. Brief description of operations *This question is required.

5. When is your renewal date

6. NEXT TWO QUESTIONS MUST EQUAL 100% IF APPLICABLE
How much work is Residential

7. How much work is Commercial

8. IF APPLICABLE
How much work is installation verses service/repair

9. What is your annual estimated payroll by class

Comments

10. Any height exposure? If so, how much, how high and what safety controls do you have in place to minimize falls *This question is required.

11. FEIN *This question is required.

12. Please upload 4 years current valued work comp loss runs *This question is required.

13. Contact Number This question requires a valid number format.