Workers Compensation

Applicant
General Information
Business
Select Agents
Finish

Applicant

Can you tell us about yourself?

First Name *

Last Name *

Email *

Phone *

General Information

Business Name *

DBA (If Applicable)

FEIN # *

Business Address

Address *

City *

State *

Zip Code *

Is the Mailing Address different from the Business Address? *

Yes

No

Mailing Address

Address *

City *

State *

Zip Code *

Organization Type *

Business

Business Information

Type of Business

# Full-Time Employees

# Part-Time Employees

Annual Sales *

Annual Payroll *

Description of Business

WC Class code 1

Class Codes

Code

Type of Work

Annual Payroll *

Prior Carrier

Do you have a prior carrier? *

Yes

No

Name of Carrier *

Enter Other Carrier Name *

Expiration Date of Policy

Have you had any losses in the past 3 years? *

Yes

No

loss 1

Loss Details

Type of loss

Date of loss *

Amount of Loss

Details of loss *

Select Agent(s) to Get Quote From:

Agent Info

Representing Companies

Agency's Agent Rep

Barry M Kamran
2072 Orchard Dr Newport Beach, Newport Beach, California, 92660
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Enhanced Plus Agents

Stephen Robert Pine
2435 North Central Expy Suite 1600, Richardson, Texas, 75080
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Your details has been submitted successfully.

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