Workers Compensation Quick Quote

Rates are Going Up on Workers’ Compensation Insurance!

Complete the Workers’ Compensation “Quick Quote” Form to see if you can save on your Workers’ Comp Ins. Now!

Click “SEND” to submit online or download and fax to (866) 560-9099. Or contact Jessica or Katie – call (888) 656-5678.

Workers Compensation Quick Quote Form

* Name/DBA:


Address:

City/State/Zip:

* Contact Person:

* Contact Email:

* Contact Phone:

Currently a member of CSBA:

 Yes No

Current Insurance Carrier:

Current Total Premium:

$

Payroll by Classification:

Class $, Class $, Class $


Above includes Owner(s) Payroll?
 Yes No

Describe below any losses/injuries in the last 3 years:

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