Workers Compensation Quote


Last Name (Contact)
First Name
M. I.
Employer Name
Trade Name or DBA
Business Type
If Other, Please Specify
How long has the
company been in business
EIN
Physical Address
City
State
Zip
County
Mailing Address (if different)
City
State
Zip
County
Email
Web site
Home Phone
Cell Phone
Work Phone
Description of Business Operations
If you are a corporation with one or two executive officers who
collectively own 100% of the corporations stock, you have the option
to exclude the officers from coverage.
Do you wish to
exclude officers?

If you are a Partnership, LLP, PLLP, LLC, PLLC, or Sole Proprietorship,
you can elect to bring partners, members or self-employed persons
under coverage for a premium that is subject to a minimum and
maximum annual remuneration.
Do you with to include
Partners, Members or
Self-Employed Persons?
If yes, include remuneration below for person(s) you wish
to bring under coverage: (Please select all that apply)
Clerical/Office
Duties
Number of Employees
Annual Payroll
Sales Person/
Collection Messengers
Duties
Number of Employees
Annual Payroll

Executive Officers/Partners/
Members/Self-Employees
Duties
Number of Employees
Annual Payroll
Other (Please Specify)  
Duties
Number of Employees
Annual Payroll
Have you ever been insured for Workers Compensation?
Have you been declined for coverage during the
last 12 months?
Claims/losses in the last 5 years
Please provide a date amount,
and description of each accident
   
 


Bradley Agency Disclaimer for On-Line Quote

By choosing to use this web site (bradleyagency.com) to request an insurance quote, you agree to the following terms and conditions.

The materials and information contained in this web site are provided “as is” and without warranty of any kind, either expressed or implied. 

The Bradley Agency assumes no liability whatsoever for damages of any kind incurred as a result of your request for a quote or use of this website.

Your request for an insurance quote will not bring into effect any insurance coverage.  Insurance coverage may only be effected when your application for insurance is accepted by the Bradley Agency and approved by the carrier as evidenced by the inception date as indicated on a policy.

Your entire quote, including the estimated premium and the prospective terms of coverage are tentative and are subject to change without notice based on any and all underwriting criteria, rating dates, manuals, plans and classifications used by Bradley Agency.

In the event that there is a difference in the information, rates, premiums or terms contained in a quote and any insurance policy issued to you by the Bradley Agency, the policy governs.

2022 Western Avenue • Albany NY 12203 • Office hours: Monday - Friday 9:00am - 5:00pm
Phone: 518.452.2736 • Fax: 518.452.2851 • Email: insurance@bradleyagency.com




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