Professional Insurance Brokers - Serving all your Insurance Needs !.....

780 NW Le Jeune Road, Suite # 626, Miami, FL. 33126
Tel. (305) 443-1177    Fax. (305) 443-0826

Workers Comp.

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Workers Comp.

For more information on any of our services, please write to us at:
E-Mail
profins@bellsouth.net

Web Site Designed by:
 Y & M Consulting, Inc.

Workers CompensationWorkers Compensation Quote Request Form

Please fill out the following form so that we may process your Workers Compensation Inquiry.

Contact information:

Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Fax
E-mail

Nature of business:

Breakdown of Payroll by Positions

Example: (Clerical, Warehouse, Driver, etc.)

Position No. 1
Number of Employees ?
Total Annual Payroll ?

Position No. 2
Number of Employees ?
Total Annual Payroll ?

Position No. 3
Number of Employees ?
Total Annual Payroll ?

Are Officers of the Corporation to be Excluded ? Yes No

Prior Coverage Information

Name of Company ? Expiration Date ?
Annual Premium Paid ? Audited Premium ?
Experience Modification (If known) ?

Losses Past 3 years?

Additional Comments:

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[Longterm Care Insurance][Business Insurance] [Employment Liability][Business]