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Workers Compensation Quote

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Workers Compensation Quote

Company Name*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Applicant Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Website
Joint Venture
Trust
Email Address*
Office Phone*
Mobile Phone
Sic Code*
EIN #*
Federal Employer ID Number, NCCI Risk ID*
Years In Business*
Date Workers Compensation Application*
MM slash DD slash YYYY
Date Of Birth*
MM slash DD slash YYYY
Title
Office Phone*
Claims
Type
Contact Information
Name*
First Last
Phone*
Email*
States Insurance Needed*
Proposed Eff Date*
MM slash DD slash YYYY
Proposed Exp Date*
MM slash DD slash YYYY
Current Policy Information*
Payment Plan*
- Annual
- Semi-annual
- Quarterly % Down
- Monthly
Current Expiration*
MM slash DD slash YYYY
Additional Notes / Comments
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Atlanta Office

Karen & King Insurance
5051 Peachtree Corners Cir
Suite 200
Norcross, Georgia 30092

Office Hours:
- Mon-Fri: 24/7
- Sat-Sun: 24/7

Glendale Office

Karen & King Insurance
200 West Wilson Blvd
Suite 2325
Glendale, California 91203

Office Hours:
- Mon-Fri: 9:00am-5:00pm
- Sat-Sun: Closed

Insurance

Policy Service

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By submitting an application through this site, you acknowledge that certain personal data disclosed as part of the application process is necessary for the purposes of evaluating and issuing insurance products to you by the insurer and its affiliates and you hereby consent to the insurer and its insurance affiliates processing such information. You understand that the insurer may share the information disclosed as part of the application process for purposes of evaluating and issuing insurance products and risk management services (including to the producer listed on the application), but that the insurer will not disclose your personal information to unaffiliated advertisers or vendors. You acknowledge that you have the right to withdraw your consent to the insurer’s use of your personal data that is deemed by the insurer to be unnecessary for the purposes stated above by notifying us in writing.

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