Workman's Comp

Here you can submit information necessary to determine a quote for worker’s compensation insurance. Your information will be submitted to a Wisecarver Insurance agent via email. An agent will be sure to give you a prompt response.

Please completely fill out the form below. All information must be accurate in order for a Wisecarver agent to insure an accurate quote. Thanks!

Business Name *:

Applicant Name *:

Phone *:

Email *:

Address *:
City *:

State *:

Zip Code *:

Driver Information
Business Structure: OtherIndividualCorporationPartnership
Description of Operation:
Number of Employees:
Total Annual Payroll: $
Number Of Years In Business:
Do you, as sole proprietor or corporate officer wish to be covered also?: NoYes
If Yes... What is your annual payroll separate from your employee payroll?:
Have You Ever Had Workman's Compensation Coverage Before?: NoYes
If Yes, When?:
Have You Had Coverage In The Last 3 Years?: NoYes
Has your campany had any claims in the last five years?: NoYes
If Yes, Please Explain:
If Yes, Date Of Claim:
If Yes, Amount Paid: $
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