Workers Compensation

MKNI Insurance Services Inc.

Workers Compensation Quick Quote

Workers Compensation



Person requesting quote
Email address
Phone number
Name of Your Company (As we provide service to your company, we will add your company name to the list.)
Escrow Office	Real Estate Office		Mortgage Lender

Client's Information
First Name		Last Name
Mailing address		What type of business operation you conduct?
Address2
City		State Zip
Home Telephone		Email Address
You can stop here and press submit, and we will call you to complete the form together; or you can continue filling in this form for a quicker quote.

Name of Company		Number of locations
Company address
City		State Zip







If There Is a Second Business Location, Please Complete This Section
Address
City		State Zip
Coverage Amount or Limit of Liability Requested
W/C Classification Code	Description Of Duties	Number of Employees	Estimated Annual Payroll for each Classification




Do you need more classification spaces?		Do you have a modification rate?
Enter modification rate		Business type entity
Do you have coverage now?		How long have you had continuous coverage?
Years in business		Workers compensation renewal date
Remarks or Additional Information

Have you had any claims in the last 3 years?
Has any coverage been declined, cancelled or non-renewed during the last 3 years?
Quotes are based on information provided. For best quote we may need to contact you for further information. Quotes are subject to availability and underwriting guide lines.
To Get the Best Price and Correct Quote for You, Please Complete These Last Few Questions
Would you like a business owners quote also?		Would you like a commercial auto quote?
Was this form easy to complete?		Name of current insurance company

Agent name
Agent name