Worker’s Comp Quote – Pfeifer Insurance

Worker's Comp Quote

Instead of filling out this form, you may send an email to [email protected] and attach the declarations page from your current policy or an application that you have already filled out.

Name *

First

Last

Phone Number

Email *

Location of business

Legal name of business

Federal Employer ID Number

Company is held as

sole proprietorship, corporation, LLC, . . . etc

Nature of business

1st Category of employees

Please 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 employees

Please 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 employees

Please provide general duties, number of employees who are in this category, part time or fulltime, and estimated annual payroll for this category.

Loss history

Additional info you wish to provide