GET A QUOTE

Please enter information below or Contact us

Company Name* :

This field is required

DBA:

Fed. Tax ID(optional):

Address*:

This field is required

City*:

This field is required

State*:

This field is required

Zip*:

This field is required

This field must contain only Digits

Phone*:

This field is required

Fax:

Email* :

This field is required

Please enter a valid email address

Is your mailing address different from the address you listed above?

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip:

This field must contain only Digits

Owner's Name:

Years in Business:

Contact:

Safety Contact:

Type of business:

  • Sole Proprietorship
  • Corporation
  • Non-Profit
  • L.L.C
  • P.C
  • L.L.P
  • Partnership

List states operating in:

Renewal date:

Current premium:

Description of Operations:

Are any of the employees union members?

Yes

No

If yes, which union?

Optional Info

Enter the Class/State/Payroll below

Class Code State Description Full Time Employees Estimated Annual Remuneration ($)
Class Code
State
Description
Full Time Employees
Estimated Annual Remuneration ($)

Documents

# File Name
{{index+1}} {{item.Name}} Download

Optional Info

Enter the Class/State/Payroll below

Class Code State Description Full Time Employees Estimated Annual Remuneration ($) Delete
Class Code
State
Description
Full Time Employees
Estimated Annual Remuneration ($)
Add New

Attach recent policy, loss runs or other policy information.

You can't submit form while it has files with ERROR. Please remove files with ERROR.
Loading...
Thank you for your submission
Error
{{error}}

Contact Info

TOUGHCOMP

28 Village Road North, 3R
Brooklyn, NY 11223

Phone: (212) 390-8772

ffas@toughcomp.com