Locally Owned & Operated by Brown's Insurance Agency, Inc. 9168 Prince William Street Manassas, VA 20110 Tel. 703-368-0333

Workers' Compensation Quote
(VA, MD, NC)
* Required fields

* How did you hear about Brown's Insurance? Please pick one I'm a current customer I Saw your Yellow Pages listing Pam Posey contacted me Bobby Tavenner contacted me Rick Brown contacted me I Saw your ad I Found you on the Internet Other
* Business Name
* Contact Name
Street Address
City, State, Zip
* Telephone
Fax
* Email Address
* What kind of work do you do?
How long have you been in business?		Years Months
How long have you had work comp insurance?		Years Months
Business Structure? SOLE PROPRIETOR PARTNERSHIP LLC CORPORATION
* Federal Employer ID Number?
Do you have a mod? YES NO		If Yes, What is it?
Claims in last 4 years? YES NO
Date	Amount	Closed		Cause
Current work comp carrier?		Policy Number
Prior work comp carrier?		Policy Number
* Expiration Date		Amount you are currently paying for work comp?
Employers Liability limits of 100000/500000/100000? YES NO
Class Code	Description	Payroll	Number of Employees	Location
Officer	Name		Include/Exclude
Pick One President Vice President Secretary Treasurer Owner Member Partner			Include Exclude
Pick One President Vice President Secretary Treasurer Owner Member Partner			Include Exclude
Pick One President Vice President Secretary Treasurer Owner Member Partner			Include Exclude
Pick One President Vice President Secretary Treasurer Owner Member Partner			Include Exclude
* Do you use Subcontractors		YES NO	If Yes, What areas?
Do you get Certificates of Insurance from Subcontractors?		YES NO
Payroll to insured subcontractors?
Payroll to uninsured subcontractors?
Other Coverage you need besides work comp?
Who writes your General Liability?
Do you need a quote on General Liability?		YES NO