AJS Insurance-Workman's Comp On-Line Quote Form

Workmen's Compensation Quotation
For the fastest and most accurate insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes only. *(Licensed in the states of AZ, NV and CA only)*

General Information

Company Name:

Contact Name:

Address:

City: State: Zip:

Day Phone: Night Phone:

Best Time To Call: AM PM

Email Address:

Company Information Needed

Federal Tax ID Number:

Enter Updated Payroll Estimates for the coming year:

Category Class Code Est. Annual Payroll

Dividend/Safety Group? Yes No

Signed loss run authorization? Yes No

Any Employees disabled or
currently on disabled leave? Yes No

Can you Fax a completed NCCI Form? Yes No Please Fax to (520) 855-8609

Can you Fax a Quarterly
or Annual Premium report? Yes No Please Fax to (520) 855-8609

Any Parties to be Excluded? (please provide details in the box below)

Additional Comments/Questions

Please enter any additional questions or comments regarding this quote.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

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General Information
Company Name:
Contact Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:

Company Information Needed
Federal Tax ID Number:
Enter Updated Payroll Estimates for the coming year:
Category	Class Code	Est. Annual Payroll






Dividend/Safety Group?	Yes No
Signed loss run authorization?	Yes No
Any Employees disabled or currently on disabled leave?	Yes No
Can you Fax a completed NCCI Form?	Yes No Please Fax to (520) 855-8609
Can you Fax a Quarterly or Annual Premium report?	Yes No Please Fax to (520) 855-8609
Any Parties to be Excluded? (please provide details in the box below)