Workers Compensation Quote Form 2016-12-13T12:10:35+00:00

WORKERS’ COMPENSATION
QUOTE REQUEST

We at Hudson & Muma believe that it is important to offer our customers the most up-to-date technology available which will enhance the service they receive. It is because of this commitment that we are offering this form to aid in generating accurate applications and forms quickly and efficiently!

Remember, without complete information, we may be delayed in producing your quote, so please complete ALL applicable fields.

SUBMITTING THIS FORM YOU ARE AGREEING TO THE CONDITION THAT NO MATERIAL CHANGE WILL BE MADE TO YOUR POLICY UNLESS AND UNTIL YOU RECEIVE CONFIRMATION OF THAT CHANGE FROM A HUDSON & MUMA ASSOCIATE OR AN ASSOCIATE THAT THE INSURANCE COMPANY WRITING THE COVERAGE.
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WORKERS' COMPENSATION QUOTE WORKSHEET

Quote Effective Date:


Insured Information

Insured or Company Name*:

Your Name*:

Phone Number*:

Your Email*

Fax Number:

Mailing Address:

Location 1 Address (if different):

Other Location Addresses (list)

Web Site:

Policy Number(if applicable):

 


 

Years In Business:

Industry Type:

If Other, describe:

Describe your business operations:

Number of Employees:

 


 

List Current Insurance and Insurance Companies:

 


 

Workers' Compensation limit desired:
None100,000/500,000/100,000500,000/500,000/500,0001,000,000/1,000,000/1,000,000

Federal Employer ID number

 


 

Payroll Codes and Estimated Annual Payroll:


Clerical-8810 Payroll:

Outside Sales -8742 Payroll:

Executive Officers-8809 Payroll:

Other Class Codes:

Code 1 Estimated Annual Payroll:

Code 2 Estimated Annual Payroll:

Code 3 Estimated Annual Payroll: