Arizona Worker's Compensation Insurance

SPECIALTY RISK INSURANCE BROKERS
Worker's Compensation


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Like other types of insurance coverages, your workers' comp insurance costs are determined by your annual premium. For example, if your workers' comp premium is under $50,000 per year, then you need a quote from an insurer who specializes in that market. Most of our worker's comp business is from small to medium size groups who are eager to save premium dollars on this government required insurance. No matter what your business classification, please complete the request for information below and we will have a no obligation quote in you hands in just a few days. Give us a try on your workers' comp business - you'll be glad you did!

We are here to help you with your commercial insurance needs.
For FREE, NO OBLIGATION information, please fill out the following form.

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If you prefer to contact us via Email, we can be reached at: srib@PacificReserve.com

Name
Arizona County
ZIP Code
Phone (Please include area code)
FAX (Please include area code)
E-mail
Preferred method of contact Phone    FAX    E-mail
I prefer to be contacted by A female agent/broker
A male agent/broker
No preference
Additional Comments

While it is not necessary for you to provide the following information, any information you would like to provide, will assist us in preparation before contacting you.
Company Name
Address
City
Zip
Federal TIN
Company Type (corp, etc.)
Years in Business
Additional Locations
Nature of Business
Number of Employees
Categories of Employes
(clerical/admin/technical/etc)
Number of employees in
each class (# full/part time),
annual remuneration per class
Current/prior worker's compensation
carrier (5 years if applicable)
Policy #
Do you receive "dividends" back from
your carrier if your company has not
had any claims?		 YES     NO
Experience Modification Rating
Coverage Limits
Current Annual Premium
How long/number-amount of claims
Anyone in your organization excluded
from your policy?
If yes, who? Title/relationship		 YES     NO
Annual Remuneration

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Copyright © 1999 Pacific Reserve, Inc. All rights reserved.
Last revised: Friday 09th of May 2008