Workers' Compensation Quick Quote
abray@farmersagent.com / jordane.abray@farmersagency.com / Phone:541-779-4825
Entity Name:
Type of Entity:
Please Select
Individual
Corporation
Partnership
LLC
Other
DBA (if applicable)
EIN:
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Contact Person and Email Address:
First and Last Name
Email Address
Estimated annual payroll for employees only, not owners of officers:
Class Code:
Job Description:
Annual Payroll:
# of Employees:
Business Description:
Please be as detailed as possible so we have a full understanding of your operations.
Number of Work Comp claims in the last 5 years (Copy of current Loss Runs may be required)
Business Owner 1
First and Last Name
Title
Business Owner 1 Cont.
% of Ownership
Excluded from Coverage?
Business Owner 2
First and Last Name
Title
Business Owner 2 Cont.
% of Ownership
Excluded from Coverage?
Additional Owners? (Name/ Title / % of Ownership / Excluded from coverage?)
I would also like to receive a quote on my Business Insurance Policy?
Yes
No
Bray Agency LLC
Phone:541-779-4825 Fax:541-770-1288 brayagencyllc.com
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