Atkins And Associates 540-286-2323
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Would you like to obtain a Workers Comp Insurance Quote?
Just complete the below form and submit.
One of our professional representatives will get in touch with you promptly.
*
Indicates required field
Name
*
First
Last
Email
*
Phone
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Insured's Name
*
Point Of Contact (If Not The Owner):
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Name Of Company:
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Type Of Business:
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Any Other Coverage Being Requested?
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EIN#:
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If Individual, Social Security #:
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Has The Business Or Its Owners Filed For Bankruptcy Within The Last 5 Years?
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Yes
No
Unsure
Amount Of Coverage Being Requested:
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100/500/100
500/500/500
1000/1000/1000
Not Sure
Years In Business:
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Description Of Business:
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Years Of Experience In This Field:
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Business Form/Type:
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Individual
Partnership
Corporation
Limited Liability Company
Prior Insurance?
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Yes
No
If Yes, Name Of Insurance Company:
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Any Claims?
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Yes
No
If Yes, Please Explain
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Is Any Work Being Performed Outside Of The State Of Virginia?
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Estimated Gross Annual Sales:
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Estimated Employee Annual Payroll
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Number Of Employees:
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Are There Any Leased Or Seasonal Employees?
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Estimated Owner/Officer Payroll:
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Are Sub-Contractors Used?
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Yes
No
If Sub-Contractors Are Used, What Percent Is Subed Out?
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If Subs are used, what types of work are sub's performing?
*
If Subs Are Used, Are They Required To Carry A Certain Limit Of Coverage?
*
Who (If Any) Was The Person Who Referred You?
*
Submit