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Attention Medical Providers: Please Click the “Medical Billing” Tab Below for our Medical Billing Address Information.

Request Quote: Workers Compensation Insurance Program

    * denotes required fields



    Address II:




    Contact Person:





    Current Insurance Carrier:

    Or Self Insured/Trust:

    Renewal Date:

    Number of Employees:

    Codes & Payroll Estimates:

    Experience Modification and or RB File #:

    (Construction Only), PAP Credit:

    To receive accurate and up-to-date information regarding your potential Workers’ Compensation Insurance coverage, please provide us with the following:

    • Number of business locations and the number of employees at each location

    • 3 year payroll audits*

    • 5 year loss runs by year*

    • 5 year premium history*

    * Depending on how long the company has been in the business ** Note: If you consider obtaining an individual insurance, i.e. non-group one, in addition to the above, please complete " NYSIF: Application for New York Workers' Compensation and Employers' Liability Insurance"

    Let GCG Risk Management determine a quote for your workers compensation insurance. Just fill out the form above as accurately as possible and we will contact you with information regarding your workers compensation insurance quote.