Worker's Compensation Insurance Quote Form

Welcome to Weber Insurance's Worker's Compensation  quote form.  To request a quote, please complete as much of the form as possible.  Use the Tab key to move from field to field.  If you leave the form, use the back button on your browser to return to the form.  This form will be emailed to us.  All information entered is confidential.

DO NOT USE THE "ENTER" KEY

USE THE "TAB" KEY  

OR YOUR MOUSE

TO MOVE FROM FIELD TO FIELD.
 

 

 
Contact Information

Name :

  
Date of Birth:  

Name of business:

  
 Mailing Address:  
City:  
State:  
Zip Code:  
Daytime phone:  
Evening Phone:
FAX:
Email Address:

 

Business Information

Federal ID # (or your SS #):  

  

Number of years in Business:  

  

Number of years covered by worker's comp:  

  

List All worker's comp claims in the past 5 years:   

Type of Work Each Employee Does:   

List Payroll Paid to each Employee:   

List All States that work is Performed in:   

 

 

 

Remarks

 

 Be patient, it will take some time for the information to be processed.  A Form Confirmation will be displayed.  Please review the information you entered.  If you need to correct any information, use the "Back" arrow on your browser to return to the form with the data you entered still in the form.  Clicking on "Return to the Form" will erase all data and return you to an empty form.

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

Are you ready to send this information? (type "YES")