Work Comp Form

In order to provide you with a workers compensation proposal we will need some information. Please provide as much detail as possible. You may want to print this form and complete it offline and return to this page to input the data.

Company Name                         Contact Name                      MC#

Address                            City                                St      Zip

Email Address               Website Address

Phone                              Fax

Fed ID Number              Emod                 NCCI Number

Current Insurance Co    Ex Date        Payment Method

Class         Annual                 # of
Code          Payroll                Empls

Do you participate in a dividend program

Please enter any other information you think may be helpful in reviewing your account.

This form will provide Insurance Strategies,LTD with the basic information needed to review your account. After receiving the above information, we will be better able to determine which programs you will qualify for and what additional information may be required. We offer quick turnaround and you should be contacted within 48 hours of submitting your information. with the basic information needed to review your account. After receiving the above information, we will be better able to determine which programs you will qualify for and what additional information may be required. We offer quick turnaround and you should be contacted within 48 hours of submitting your information.