Workers Comp Insurance Quote Jacksonville

Business Name:
*Premises Address:
*City:(Florida)
*Zip Code:
*Contact Name:
*Phone #:
Ext #:
Fax:
Years in Business:
*Email Address:

Type of Business: Select One Individual Partnership Corporation LLC Subchapter S Corp. Nonprofit Other
If Other, Please Specify:

Description of Operations or Payroll by Class Code:



# of Full-Time Employees:
# of Part-Time Employees:
# of Locations:
Estimated Annual Payroll: $
Experience Mod: (if any, per policy)

Do you require increased limits? If so, please state limits needed.

Recent Insurance Information

Current Insurance Company:
Policy #:
Policy Expiration Date:
(mm/dd/yyyy)
Requested Effective Date:
(mm/dd/yyyy)

Does your current policy include any of the following:
Deductible? Select One Yes No
If yes, how much?

Safety Credit? Select One Yes No
Drug Free Workplace Credit? Select One Yes No
Dividend Program? Select One Yes No
If yes: please describe.


Losses past 3 years: Select One Yes NO

If yes: please describe losses, or if possible, please include currently valued loss runs:


Additional Information or Comments: