Workers Compensation

Workers compensation is a state-mandated, "no-fault" insurance system that pays benefits to workers injured on the job to cover medical care, part of lost wages and permanent disability. In return, employers receive immunity from civil lawsuits by employees over such workplace injuries. Employers can meet their workers compensation obligation by purchasing insurance or by becoming a state-certified self-insurer.

WORKERS COMP FORM- PLEASE COMPLETE FOR A QUOTE

We are licensed in these states: NY, NJ, PA, NH, CT, and MA.
We have been very success in writing policies for the following businesses: Electricians ~ Plumbers ~ Landscapers ~ Construction ~ Deli ~ Printers ~ Garage / Auto Mechanics ~ Distributors ~ Computer Stores
Applicant Information - GENERAL INFORMATION
Your Line of Business
First Name*
Last Name *
Company Name *
Mailing Address (First Named Insured): *
City*
State*	Zip*
FEIN or Soc Sec # (of First Named Insured):*
Phone *
E-Mail Address *
Fax
Company Information
Select One * Individual Partnership Corporation Joint Venture Subchapter “S” Not For Profit Org LLC # of Members
Years in Business
Proposed Effective Date

Workers Compensation

PAYROLL CLASSIFICATION 1

Categories, Duties

# Employees Full time

Part Time

Estimated Annual Pay Roll

PAYROLL CLASSIFICATION 2

Categories, Duties
# Employees Full time		Part Time
Estimated Annual Pay Roll

PAYROLL CLASSIFICATION 3

Categories, Duties
# Employees Full time		Part Time
Estimated Annual Pay Roll

Officer (1) to be Included/Excluded
Name
Title
Duties
Included/Excluded
Class Code
Payroll

I/We hereby authorize any credit bureau or any other investigative agency to investigate the references herein listed or statements or other data obtained from me / us or from any other person pertaining to my / our credit and financial responsibility.

I / We represent, warrant and affirm that all of the statements made by me / us in this application are true and correct.

Fair Credit Reporting Act disclosure: This application is for insurance purpose only and can be submitted to various Insurance companies for the purpose obtaining insurance policy (policies).

Comments/ Questions

* By checking this box - you are agreeing to the information above. This will serve as an electronic signature.

CALL (516) 944-7520 FOR MORE INF

When calling please ask us about our dividend program from various insurance companies that we represent. Only a hand full of insurance companies have safety groups, so call us to see if we can get your company into a group and see big savings right away.

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