* denotes required fields

Company:

Address:

Address II:

City:

State:

Zip:

Contact Person:

Title:

Phone:

Fax:

Email:*

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.

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