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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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Thank you for visiting The Griffin Maclean Agency Website.    |    WA Ins. License # GRIFFML190JP
E-Mail: paul@griffinmaclean.com   |   More About our Agency's Services
2300 130th Avenue NE, A203    Bellevue, WA 98005   (Click for Map/Directions)
Phone: 425-822-1368    |    Fax: 425-822-2737   |   E-mail us at: paul@griffinmaclean.com
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