Workers Compensation Insurance Quote Form

Please fill out this form to the best of your ability. Our team here at Quantum Insurance Group will follow up with you promptly!

Business Contact Information

Company Name *

Company Owner *

DBA Name

First Name *

Last Name *

E-Mail Address *

Primary Phone Number *

Alternate Phone Number

Street *

City *

State *

ZIP / Postal Code *

FEIN#

Business Information

Business Type

Do you currently have insurance?

Current Insurance Provider

Expiration Date

Nature of Business

Year Business Established

Number of Owners

Number of Employees

Annual Employee Payroll

Amount of Desired Insurance

How did you hear about us?

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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3140 Finley Road, Suite 400F | Downers Grove IL 60515 | 630.964.1360 | info@quantumagencies.com