Workers Comp Insurance Quote - The Figleaf Agency

Step 1 of 3 - Tell Us About Yourself

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Your Personal / Company Information
*
First Last
*
*
Street Address
*
City
Must Be New Jersey*
State
Address*
ZIP Code
*
Enter Email Confirm Email
*
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
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 #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: $
Describe IN DETAIL, Your Business Operations*

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