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Workers' Compensation Insurance Quote


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Company Information
Company Name
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Legal entity type
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Street
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City
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State
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ZIP / Postal Code
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E-Mail Address
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Business Website Address
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Primary Phone Number
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Alternate Phone Number
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Federal Employer's Identification Number (FEIN)
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How did you hear of our agency?
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If by referral, who referred you?
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Any problems with current insurance we can help solve?
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Company Owner
Number of Owners
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First Name
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Last Name
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Additional Owner Name
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Additional Owner Name
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Additional Information
Describe Your Business
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Number of Employees
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Annual Employee Payroll
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Subcontractors Used
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Annual Cost of Subcontractors
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Prior Insurance
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Length of Coverage (Months and Years)
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Describe any claims/losses in the past 5 years
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When was business established?
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If business is new, describe owner's prior experience in this type of work and other business management/ownership:
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Add notes here:
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Rating Classifications
Clerical Employees Annual Payroll
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Sales Employees Annual Payroll
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Driver Employees Annual Payroll
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Description Of Other Employee Work
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Annual Payroll For This Work:
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Add notes here:
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Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Boer Insurance Group | 2535 Five Mile Road NE, Grand Rapids, MI 49525 | Ph: 616-363-7766 | Fx: 616-363-6626
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