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Bromell Agency Inc.

Your Full Service Insurance Agency

 

 
Workers' Comp
INSURANCE
QUOTE		   We would like to provide you with a free, no-obligation Workers' Compensation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
 

General Information
Name of Business:
Contact Name:
Address:
City:   State:   Zip:
Business Status:     Other:
Business Tax ID Number:
Business Phone:   Fax:
Best Time To Call:   AM   PM
Contact Email Address:


Current Insurance Information
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
NCCI Number:   NCCI Experience Modification Number:
What type of coverages do you currently have:
Bond
Commercial Auto
Commercial Liability
Commercial Property		 Commercial Umbrella
Directors & Officers Liability
Disability
Group Health		 Group Life
Professional Liability
Other  


About Your Business
# of full-time
employees
# of part-time
employees
How long
in business
How many
locations
Estimated Annual
Payroll
years
$
Please give a brief description of your business(below):


Employee Information.
Employee#
Classification code
Estimate Yearly Payroll
1
2
3
4
5
Please list additional employees in the "Additional Comments" section below


Business Information
Please select all that apply to Business:
Operate or Lease aircrafts/watercrafts
Store, treat, dispose or transport hazardous waste
Work Underground
Work above 15ft.
Work on vessels, docks or bridges over water
Require out of State travel		 Use Subcontractors
Delivery Service
Pre-employment Physicals
Offer Safety and Incentive programs
Other  


Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   

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