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On-Line Workers Comp
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal / Company Data:

Your Name:
Your Company's Name:
Street Address:
City:
State:
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.)
 
FEIN or Social Security #:
(now required by all comp carriers to quote)
 


 
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:
$
 
 
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WE REPRESENT THE NATION'S FINEST INSURANCE CARRIERS
& SHOP MULTIPLE COMPANIES TO GET YOU THE BEST VALUE AND COVERAGE!

All United Insurance Agency represents the following insurance companies


Our Office Locations & Contact Information:

All United Insurance Agency, LLC | 990 South 2nd Street, Suite 4 | Ronkonkoma, NY 11779
Phone: 866-484-8656 | Fax: 866-362-9807

All United Insurance Agency, LLC | 13860 Ballantyne Corporate Place, Suite 120 | Charlotte, NC 28277
Phone: 866-484-8656 | Fax: 866-362-9807

Email: quotes@allunitedinsurance.com | About Us | Policy Service Request | Privacy Notice



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