Worker's Comp QuoteInstead of filling out this form, you may send an email to alex@pfeiferins.com and attach the declarations page from your current policy or an application that you have already filled out.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone NumberEmail *Location of businessLegal name of businessFederal Employer ID NumberHeld asSole ProprietorPartnershipCorporation"S" CorpLLCJoint VentureTrustOtherNature of business1st Category of employeesPlease provide general duties, number of employees who are in this category, part time or fulltime, and estimated annual payroll for this category.2nd Category of employeesPlease provide general duties, number of employees who are in this category, part time or fulltime, and estimated annual payroll for this category.3rd Category of employeesPlease provide general duties, number of employees who are in this category, part time or fulltime, and estimated annual payroll for this category.Loss historyAdditional info you wish to provideSubmit
