Workers Compensation Insurance | Somerset Insurance Solutions

Company Name*

Company Address*

Street Address Address Line 2 City State ZIP Code

FEIN (Federal Employee Identification Number)*

(omit dashes)

Primary Contact*

First Last

Contact Email*

Contact Phone*

Total Annual Payroll*

Total Employees*

Please enter a number from 0 to 100.

Full Time Employees*

Please enter a number from 0 to 100.

Part Time Employees*

Please enter a number from 0 to 100.

Type of Work*

Please provide an overview of the type of work your employees perform ie. job function. This will allow us to provide a more accurate quote.