Worker's Compensation Quote Request: - Irving Weber Associates, Inc.

Worker's Compensation Quote Request

Broker/Agency Name*
Broker/Agent Contact Name*
First Last
Broker/Agent Phone*
Broker/Agent Email*
Enter Email Confirm Email
Insured Company Name*
Insured Contact Name*
First Last
Insured's Mailing Address*
Street Address Address Line 2 City State ZIP / Postal Code
Insured's Federal ID Number
Policy Effective Date*
Date Format: MM slash DD slash YYYY
Do they currently have coverage?*
Name of Current Carrier
Class Code/Payroll*
Class Code Yearly Payroll
Coverage Limit*
- 100,000/100,000/100,000
- 500,000/500,000/500,000
- 1,000,000/1,000,000/1,000,000
- Other - List Below
Other Coverage Limit:
Have there been any Claims in the last 4 years? If yes, please give details.*
- Yes
- No
Details of Claims
Other Information for Underwriter?

Going Beyond Insurance

Our approach to the niche markets we serve is to enhance the way in which we integrate risk management and insurance solutions into our customers’ business operations. This has been part of our tremendous success with all of our programs and why so many come to IWA to help protect their assets, property, employees and customers. We’d like an opportunity to show you what we can do for you. Contact us today at 800-243-1811 for more information.

Content on this website is strictly informational and should not be used as specific advise on insurance products, legal, accounting, and/or tax related matters. Insureds should always contact the appropriate licensed professional for their insurance, legal, accounting, or tax needs.

Class Code	Yearly Payroll