Phone: (781) 641-3300

Fax: (781) 777-1402

 

Workers Comp Insurance Request

Helpful Info

We would like to provide you with a free, no-obligation insurance quote. Please provide as much information as possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Please be sure to supply your phone number and email address so that we may contact you after receiving this notification.

Current Insurance Information

What type of coverages do you currently have:

About Your Business
Employee Information

Employee 1

Employee 2

Employee 3

Employee 4

Employee 5

Please list additional employees in the Additional Comments on Step 6.

Business Information

Please select all that apply to business:

Additional Comments