Workers Comp Quote from TC Irons Haines & Haines Insurance

Privacy Policy-We routinely collect personal and/or business information that is needed as part of the quoting and underwriting process. We also collect the same information as part of service and update activities. The Haines & Haines/T.C. Irons Agency will not share that information, or use it in any other way, with outside parties, vendors, etc.

Workers Compensation Quotation

GENERAL BUSINESS INFORMATION

Name of Corp./Business

Business Structure
(Check One) INC CORP LLC
SOLE PROPRIETOR
PARTNERSHIP
OTHER

Federal Tax ID

DBA (if applicable)

Business Address

City

State

Zip Code

Business Web site Address

EXPERIENCE & BASIC RATING INFORMATION

Please Describe the
Nature of Your Business

NCCI Exp. Mod Factor (if available)

# of Owners

# of Employees

# of Years This Business Name

Annual Payroll Owners

Annual Payroll Employeesers

COVERAGE REQUEST

Coverage Requested

Other Coverage Limits

Include Owners in Coverage? YES No

Are There Any Losses-Claims in the Last 5 Years? YES No

If Losses and/or Claims
List - Date, Amount Paid and Description of Each Loss

CURRENT COVERAGE INFORMATION

Current Insurance Carrier

Current Expiration Date

Current Premium

CONTACT INFORMATION
First Name Last Name Email Phone Fax Questions / Comments / Notes
Send my quotation via	E-Mail Fax Regular Mail Call me by Phone!

All quotes are based on the information that the applicant provides, and are subject to change based on final underwriting by the individual carriers.

Our Mission Statement

Dating back from 1872 our mission is clear:

To serve our clients with the utmost respect, integrity and professionalism while providing a comprehensive risk management program at competitive pricing

Policy Coverage
and Disclaimer

Contact

	Haines & Haines/ T.C. Irons
16 West Front Street Florence, NJ 08518 Phone: 609.499.0237 Fax: 609.499.4077	230 High Street PO Box 158- Burlington, NJ 08016 Phone: 609.387.0606 Fax: 609.387.5337	1-3 Bank Street Suite E Medford, NJ 08055 Phone: 609-953-2282 Fax: 609.953.7719
	Wesley Insurance Service Agency 1194 Parkway Avenue Trenton, NJ 08628 Phone: 609.883.4190 Fax: 609.538.0274