AlphaGen Insurance - Workers' Compensation Quote Request

AlphaGen Insurance - Workers' Compensation Quote Request

Request a workers' compensation quote by providing your contact details, business information, payroll and class code data, experience and safety details, current coverage, and optional supporting documents.
Contact
Full Name

First NameLast Name
Title
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Business Info
Legal Business Name
DBA
Entity Type
FEIN
State(s) of Operation
Years in Business
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Business Description / Operations
Website
Payroll & Class Codes
Total Annual Payroll ($)
Number of Full-Time Employees
Number of Part-Time Employees
Owners/Officers Included?
Number of Owners/Officers
Primary NCCI Class Code
Payroll by Class Code
Subcontractors Used?
Annual Subcontractor Cost
Certificates of Insurance Obtained from Subs?
Experience & Safety
Current Experience Modification (Mod) Factor
Any prior workers' compensation claims in the last 5 years?
Number of Claims
Total Incurred Losses ($)
Largest Single Claim ($)
Written Safety Program?
Drug-Free Workplace?
Return-to-Work Program?
Current Coverage
Current WC Carrier
Expiration Date

MonthDayYear
Date
Current Annual Premium
Reason for Shopping
Effective Date Desired

MonthDayYear
Date
File Uploads
Current Dec Page

Cancelof
5-Year Loss Runs

Cancelof
ACORD 130 Application

Cancelof
Most Recent NCCI Experience Mod Worksheet

Cancelof
Payroll Summary / 941

Cancelof
Other

Cancelof
Additional Info
Anything else we should know?
Referral source
Should be Empty:

AlphaGen Insurance - Workers' Compensation Quote Request

Contact

Business Info

Payroll & Class Codes

Experience & Safety

Current Coverage

File Uploads

Additional Info