Resources

Workers' Compensation Quote Form | Forms | Newsletters

Workers' Compensation Insurance Quote Request Form

Please complete this form as accurately as possible and submit it to us.
You may also print out the form and fax it to us.
Fax: (248) 488-1980

Contact Information:

Name of Business:

Contact Name:

Street Address:
(please Incl. ste/apt etc.)

City:

Zip/Postal Code:

Federal Employer Identification Number:

Phone (Business):

Fax:

E-mail:

Proposed Policy Effective Date:

Nature of Business:

Number of Locations in Michigan:

Does your company own or operate any aircraft or watercraft?

yes no

yes:
watercraft aircraft

Current Insurance Company (not agency):

Company Name:

Policy Expiration Date:

Estimated Payroll by Classification (Enter one or more locations):

Code 1:

Classification 1:

Payroll 1:

# of Employees:

Code 2:

Classification 2:

Payroll 2:

# of Employees:

Code 3:

Classification 3:

Payroll 3:

# of Employees:

Code 4:

Classification 4:

Payroll 4:

# of Employees:

Experience for the Last Five Years:

Coverage Date(s):	1st:
	2nd:
	3rd:
	4th:
	5th:

Gross Payroll:

Incurred Losses:

Exp. Mod.:

Losses Over $20,000 in the Last Five Years:

Date:

Injury Type:

Incurred:

OP/CL:

All information is required.

MTMIC always keeps your information confidential.

Once you have completed the above form, please hit 'Submit Information' ONLY once.

Thank you.

Serving the Manufacturing and Tooling Industry Since 1976 • Vigilant Claims Management and Aggressive Loss Control

P.O. Box 9150, Farmington Hills, Michigan 48336 | Phone 248.488.1172 | Fax 248.488.1980
Web design and hosting by Infinite Creations