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E-Mail:
vickie@contractors
1stinsurance.com

Toll Free Phone:
800-238-4654

Insurance License
Numbers:
CALIFORNIA OE61983
TEXAS 1416119
ARIZONA 873215
COLORADO 277626
LOUISIANA 417236
NEVADA 634600

Contractors We Write:

• Framers
• Roofers
• HVAC
• Drywall
• Plasterers

• Masonry
• Concrete
• Sanitation
• Janitorial
• Plumbers

• Electricians
• Low Voltage
• Landscapers
• Grading
• Excavation

• Paving Contractors
• New Home Builders
• Artisan Contractors
• Tile Contractors
• Pool Contractors

• Welders
• Steel Contractors
• Sheet Metal
• Ornamental Metal
• Pipeline Contractors

• Floor Installers
• Cabinetmakers
• General Contractors
• Remodelers
• Home Builders

• Commercial Contractors
• Developers
• Tract Home Builders
• Condo Builders
• Many More!

On-Line Workers Compensation Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal / Company Data:
Your Name:
Your Company's Name:
Street Address:
City:
State:
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again (for accuracy):
Phone:
Fax (optional):


Currently Insured? (If yes, list carrier, and # of years continuous. If none, type NONE)

List Claims & Amounts Paid (If none, type NONE)

Years In Business:

Business type: (proprietorship, corporation, etc.)


Underwriting Information:

Describe IN DETAIL, Your Business Operations:

Payroll Class #1:
List Class Code # if you know it, and describe payroll class:	Insert Annual Payroll in dollars for this class here:	$

Payroll Class #2: (if none, leave blank)
List Class Code # if you know it, and describe payroll class:	Insert Annual Payroll in dollars for this class here:	$

Payroll Class #3: (if none, leave blank)
List Class Code # if you know it, and describe payroll class:	Insert Annual Payroll in dollars for this class here:	$


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