Workmans Compensation Quote 

Workers Compensation Insurance Quote

Please fill out all requested information below as so we may be able to provide a competitive quote in a timely manner.



company name:
contact name:
 
work phone:
 
home phone:
 
fax:
    
email:
    
mailing address:
    
city:
 state: zip:
tax id:
    
     
Best time to contact:
 morning afternoon night
       
type of business/ provide a detailed description
of operations:
year business started:
    
requested start date:
    
     
current insurance carrier:
 
policy number:
    
expiration date (mm/dd/yy):
    
total premium:
    
     
any claims in last five years?
 yes no    
Is company canceling coverage:
 yes no    
     
employee payroll figures
      
class code:
 F/T P/T
annual payroll renumeration:
class code:
 F/T P/T
annual payroll renumeration:
class code:
 F/T P/T
annual payroll renumeration:
class code:
 F/T P/T
annual payroll renumeration:
 
 
owners included/excluded
 included excluded    
owner name:
owner name:
title/relationship:
title/relationship:
 

   




Cossio Insurance Agency PO Box 188 Simpsonville, SC 29681 p:864-688-0121 f:864-688-0138