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Workers Compensation Insurance Quote Request
To receive a free insurance quote from the Perrine Agency, answer the following questions and submit.  An agent will analyze your information and contact you shortly.  You may also print out this page, fill in at your convenience, and fax to us at (952) 888-1134.

 YOUR INFORMATION
 
  Company Name
 
  Your First Name
 
  Last Name
 
  Street Address
 
  City
 
  State
 
  Zip Code
 
  Phone - include area code and extension
 
  Fax - include area code
 
  Email Address
 
Type of Business:    Sole Proprietor    Corporation  Partnership
LLC  Association
Yes    No  -   Do You Currently Have Workers Comp Insurance?

 If yes, who is your current insurance company? 

 If yes, when does your current policy expire? 
 Describe your business operations:

 
Year Business Established: 

Years at Current Location:  
Check the following that applies to your office space:
Own    Lease   Neither
Number of Locations:   
Number of Employees:   
Annual Gross Revenue: $ (approx.)
Company Payroll (Total): $ (approx.)
Amount of Insurance Desired: $
Number of Company Vehicles:   
Have you been named in a lawsuit in the past 2 years?

Yes    No

If yes, briefly explain:

 
  OPTIONAL COVERAGES
 
Check any additional policies you may be interested in:
 
Group Health Business Property Malpractice
Workers Comp Errors/ Omissions Commercial Auto/ Truck
Other Business Owners  

What is the best time of day to reach you by phone? 

Enter any comments/ questions/ suggestions below:

Click below to submit information.

 
 


"Don was able to find us the best package to meet our needs at the best price and provided friendly, personal service.  Glad we found you!"

Kevin & Jill Unterreiner
Eden Prairie, MN