Workers Comp Service Request

Service Request

Please complete all questions.
Person Completing Form*

First NameLast Name
E-mail*
example@example.com
Phone*
Referral Email
example@example.com
Would you like us to contact you before we contact client?*
#Prospective Client Information
Client Company Name*
DBA, if any
Contact Person
Phone*
Please enter a valid phone number.
Email*
example@example.com
Best Time to Call

Hour Minutes

AM/PM Option
Proposed Effective Date

MonthDayYear
Date
Currently Insured?
Main Industry of Client*
Website
City/State*
# of Emplyees
Coverage/ Quote Requested (Check all that apply)
Workers' CompensationGeneral LiabilityCommercial AutoCommercial PropertyEmployment Practices LiabilityOther business insuranceEmployee health benefitsVision, Rx, Dental, Accident/OtherExecutive Planning
Any additional details
Upload any files that might be needed

Cancelof
Note: If prior coverage, (loss) history is available, please fax or email it along with this application. Reminder that all documented loss history must be dated within 30 days of the date of this application to be considered valid. We will assist in the collection of this data.

Please make client aware of our call and please make sure that you put YOUR name and contact information at the top of this sheet! The information above will greatly expedite our underwriting and allow us to pre-fill the application to simplify the process for your client! If you do not have access to this form, simply email as much information as you have and we will begin processing ASAP!
Please verify that you are human*
Should be Empty:

Service Request

#Prospective Client Information

Coverage/ Quote Requested (Check all that apply)