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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
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Company Owner
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DBA Name
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First Name
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Last Name
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E-Mail Address
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Primary Phone Number
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Alternate Phone Number
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Street
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City
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State
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ZIP / Postal Code
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FEIN#
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Business Information
Business Type
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Do you currently have insurance?
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Current Insurance Provider
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Expiration Date
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Nature of Business
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Year Business Established
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Number of Owners
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Number of Employees
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Annual Employee Payroll
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Amount of Desired Insurance
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How did you hear about us?
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Submission Validation
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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

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