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Home > Workers Compensation > Secure Worker's Comp Insurance Quote
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Secure Worker's Comp Insurance Quote


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Business Information
Business Name
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
Fax Number
E-Mail Address *
Business Type
Industry
Describe your Business
Annual Gross Sales
Number of Full Time Employees
Number of Part Time Employees
Estimated Monthly Payroll
Number of Locations
Years in Business
Federal ID #
Business Type 2
License Number
Owners/Partners/Officers( Include yourself if applicable)
Number of Owners/Partners/Officers
Owner 1
First Name *
Last Name *
Date of Birth
/ /
Title
Ownership %
Owner 2
Owner Name (First, Last)
Date of Birth
/ /
Title
Ownership %
Owner 3
Owner Name (First, Last)
Date of Birth
/ /
Title
Ownership %
Owner 4
Owner Name (First, Last)
Date of Birth
/ /
Title
Ownership %
Owner 5
Owner Name (First, Last)
Date of Birth
/ /
Title
Ownership %
Payroll Information
Employee Group
Class/Code
Payroll Rate
Annual Payroll
Misc. Information
Do you offer safety programs?
Do you offer health benefits?
Do you employ any minors?
Do you use sub-contractors?
Do you use any equipment that bends/forms/shapes?
Do you sponsor any athletic teams?
Do you do any work up over 15 feet?
Is the business open 24 hours?
Is the business involve any deep frying of foods?
Is the business involve any filling of propane tanks?
Have you filed bankruptcy in the past 7 years?
Are you a member of any trade organization?
Do you have operations outside the state where you are domiciled?
Coverage Information
Current Carrier Name
Policy Expiration
Current Policy Premium $
MOD Factor
Coverage Description
Has coverage lapsed in past 12 months?
New Coverage Liability Limit
Losses/Claim
Number of Losses Claimed in Past 5 years
Additional Information
Agent Name (Optional)
How Did You Hear About Us ?
Preferred Contact Method
Additional Comments
Acknowledge "Important Notice" below was read *
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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1802 S Parrot Ave
Okeechobee, FL 34974
P: 863-763-7711
F: 863-763-5629

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