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Work Comp Insurance QUOTE

Centerpoint Insurance Group will work closely with you to understand your business and determine your insurance needs. We offer comprehensive programs with coverage enhancements and pricing that separates us from many of our competitors.

WORK COMP INSURANCE QUOTE REQUEST FORM

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.

   
 
3900 E. Mexico Avenue, Suite 850 • Denver, CO 80210 • 888-933-0375 • 303-333-1391 Fax • Info@cptins.com