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workers compensation Insurance Quote Form

Employers have a legal responsibility to their employees to make their workplace safe. However, accidents happen even when every reasonable safety measure has been taken.

To protect employers from lawsuits resulting from workplace accidents and to provide medical care and compensation for lost income to employees hurt in workplace accidents, businesses are required by law to purchase worker’s compensation insurance. Worker’s compensation insurance covers workers injured on the job, whether they’re hurt on the workplace premises or elsewhere, or in auto accidents while on business. It also covers work-related illnesses.

Worker’s compensation provides payments to injured worker, without regard to who was at fault in the accident, for time lost from work and for medical and rehabilitation services. It also provides death benefits to surviving spouses and dependents.

Worker’s compensation insurance must be purchased as a separate policy. Although, in-home businesses and business owner’s policies are sold as package policies, they do not include coverage for employee’s injuries.

For more information, please feel free to contact us at 877-9-THE FIG. You can also complete the questionnaire below to be contacted by one of our agents.

Your Personal / Company Data:

Your Name:
Your Company's Name:
Street Address:
City:
State: MUST be New Jersey!
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again (for accuracy):
Phone:
Fax (optional):
 


Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
 
List Claims & Amounts Paid
(If none, type NONE)
 
Years In Business:
 
Business type:
(proprietorship, corporation, etc.)
 


 
Underwriting Information:
 
Describe IN DETAIL,
Your Business Operations:
 
Payroll Class #1:
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here:
$
 
Payroll Class #2: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here:
$
 
Payroll Class #3: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here:
$
 
 
Send my quotation via: E-Mail Fax
Regular Mail

 
Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a
Workers Compensation Quote NOW!


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