Insurance Resources for Florida Residents and Business Owners
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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: MUST be Florida!
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
 
Rate Your Credit History and Past Insurance Payment History:
(Some companies products are
based on your credit and payment history.) 		Excellent Fair
Poor Horrible

Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
 
List Claims & Amounts Paid
(If none, type NONE)
 
Do You Have Loss Runs and/or Experience Rate Mods.?
(If yes, please explain what
documentation you have available:)
 
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: 		$
 
 
Send my quotation via: E-Mail Fax
Regular Mail

 
Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Workers Compensation Quote NOW!

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Cronin Insurance Agency
 11395AA West Palmetto Park Road
Boca Raton, FL 33428
Toll Free: 1-888-427-6646
Phone: 1-561-479-1898
Fax: 1-561-479-1386
E-Mail: petercronin@cronininsurance.com
Web Site: www.cronininsurance.com

Terms of Use/Privacy Notice/Copyright Info. Cronin Insurance Agency.    Design © 2005 Insurance-Web-Sales
Please report site-related technical problems to: petercronin@cronininsurance.com (This page last updated March 30, 2005)