Florida Worker Comp Insurance Quote

Business Name:    
Premises Address:
City:  
Florida
Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required) 

About Your Florida Business:

Federal Employer's ID #:
Description of Operations or SIC code:


# of full-time employees:     # of part-time employees:
# of locations:     Estimated Annual Payroll: $
Experience Mod (if any, per policy)

Select all that apply to your Florida business:
Operate or lease aircraft/watercraft     Work Underground
Work above 15 feet                           Require out of state travel
Use Subcontractors                            Delivery Service
Pre-employment physicals                   Offer safety incentive programs
Store, treat, dispose, or transport hazardour waste
Work on vessels, docks, or bridges over water
Other

Recent Insurance Information:

Current Insurance Company: 
Policy #: Expiration Date: (mm/dd/yyyy)
Losses past 3 years: Select One Yes NO
Description of losses or loss runs:


Which insurance coverages do you currently have:
Florida Commercial Auto
Florida Commercial Liability
Florida Commercial Property
Florida Workers Comp
Florida Group Health
Florida Group Life
Florida Group Disability
Florida Group Long Term Care
Other

Florida Employee Information:

Employee       Classification Code       Yearly Payroll Estimate
      1                                         $
      2                                         $
      3                                         $
      4                                         $
      5                                         $

Officers / Partners / Owners Information:

Principal             Name                                           Title                        Include
      1              Select Yes NO
      2              Select Yes NO
      3              Select Yes NO

Additional Information or Comments



Click on the "Submit Quote Request" button below to send
your Florida Worker Comp Insurance quote request.**

**Information received from this Florida Worker Comp Insurance quote
request form sent to "YOUR AGENCY NAME" will be for our use
only and will not be sold, given to or distributed to any other parties. A quote
quote will be based on the Florida worker comp insurance information
provided and does not guarantee acceptance of the risk by us. The precise
coverage afforded is subject to meeting underwriting guidelines, and the
terms, conditions and exclusions of the policy as issued. By submitting this
request you acknowledge that this is neither an offer to insure nor a
guarantee of insurance. Completion of this form does not entitle your
business to a Florida Worker Comp Insurance policy. We are
licensed in Florida and will not provide worker comp insurance quotes
in other states.

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Florida Business Information:

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