Workers Compensation Insurance for Fort Worth Dallas and all of Texas by Will Rogers Insurance

Workers Compensation Quote Form

Please fill in the information below to receive a quote

Primary Contact First Name Last Name

Company:

Years Company has been in Business

Company Type:

Number of Owners: Gross Sales

Tax ID or EIN

Number of Employees: Exclude Owners from coverage (check box if yes)?

Company Address:
City: State: Zip

Phone:( ) - Fax:( ) - Email:

Type of Business & Description:

Please Describe Business in Detail:

States you do business In (Ctrl + Click to Select Multiple States)

Reason for Quote

Current Workers Comp Insurance Company (not agency):

Workers Comp Policy Expiration Date:

Workers Comp Policy Liability Limit:

Loss Modifier Code (will show on your dec page) NCCI # if Known

Workers Comp Losses in last 3 years?

Please describe any WORK COMP Losses give details and give dates

List Class Codes if known, Job Description, and Annual Payroll by Job Type
Class Code	Job Description	Employees in Job Class	Annual Payroll for Job Class
8810	Example - Clerical office	3	$ 90,000
			$
			$
			$
			$
	Gross Annual Payroll		$

Do you use sub contractors?

How did you find out about us?

Please fill in the information in the graphic below then hit send me a quote.