Worker’s Compensation Quote – Colorado Springs CO

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Company Info

Name*

First Last

Company Name

Company Type

# of Owners, Members, or Officers

Do the Owners Wish to be Covered?

Address

Street Address City ZIP Code

Email

Phone

EIN#

Currently Insured?

Name of Carrier

How Long Insured

Claims for past 3 years - Provide details / dates

Please Describe Work Performed by Employees (classification groups)

Emp. Group 1 (Classification)

Group 1 - Annual Payroll

Group 1 - # of Employees

Emp. Group 2 (Classification)

Group 2 - Annual Payroll

Group 2 - # of Employees

Emp. Group 3 (Classification)

Group 3 - Annual Payroll

Group 3 - # of Employees

Emp. Group 4 (Classification)

Group 4 - Annual Payroll

Group 4 - # of Employees