Workers Comp

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Just fill out below and click submit and we will get to work.
If you prefer to call, reach us at 800-591-9692.

Date:
Time of Request:
Business Name:
Contractor License Number:
How did you hear about us?
Referral if so by
Flyer
Current Client
Had Prior First Service Policy
Online Search
Phone Book
Other

Owner/Contact Name:
*Business Phone:
Fax:
*Email:
Description of your operation:
Estimated Gross Annual Receipts:
Estimated Annual Field Payroll:
Estimated Annual Sub-Out Cost:
If you have a breakdown of Estimated Annual Payroll by
Class, provide below:
1 Class:
Annual Payroll:
2 Class:
Annual Payroll:
3 Class:
Annual Payroll:
4 Class:
Annual Payroll:
5 Class:
Annual Payroll:
FEIN #:
Current Insurance Carrier:
Policy Expiration Date:
Any claims in the last five years?
No claims.
Yes,
If so please provide a brief detail of the number and the $ amount of claims with dates. We will work to get the best quotes and be in touch for more detail.
Are you satisfied with your old broker's service?
Yes
No, then What is the problem with your old Broker?

Please note that insurance transactions, – requests to incept, change or otherwise alter coverage, – are NOT effective without written acknowledgement from the carrier issuing coverage. First Service will notify you in writing when the carrier has confirmed your request.