Employment Opportunities with Haines & Haines/T.C. Irons

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	-- NJ PA NY DE
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	***SELECT*** $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000+ OTHER - Enter Below
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.

 

 

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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.

Policy Coverage and Disclaimer