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Florida Workers Compensation Proposal Request
Company Information
Company Name:*
Your Name
Phone Number*
E-Mail:*
Important: Enter a valid e-mail address.
Business Description
Please describe your business operations :
Do you work outside the State of Florida?
Yes
No
How many years experience do you have in this field?
How many employees do you have?
Do you wish to cover Company owners?
No - Owners are excluded from coverage
Yes - Please include on policy
Not Sure, Please explain
Policy Rating Information
Do you have coverage now?
Yes
No
If so, What dates does it expire?
Have you had any claims in the past 3 years?
No Claims.
Yes, Have loss runs.
Yes, Do not have loss runs.
Annual Payroll ( Do not include owners/officers)
Annual Owners Payroll
Estimated Gross Annual Sales:
Annual Payroll Breakdown Information
Please provide annual payroll for each employee and what type of work preformed. Example:
John Smith 35,000 Flooring Installer
Tom Jones 20,000 Residential Carpenter
Mike Smith 49,000 Supervisor
Tami Brown 30,000 Secretary
Bill Smith 25,000 Painter
Please click submit below. An agent will email you within 24 hours. Thanks!
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