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Workers' Comp Coverage Quote

Yes, please contact me about a Workers' Comp Coverage Quote.

Fill out the form below if you would like further information about starting the workers' compensation coverage quote process with Chesapeake Employers.
 
*Any business, other than domestic worker or sole proprietors, are required to be registered with the Maryland Department of Assessments and Taxation (SDAT). Visit the Maryland SDAT website for more information to register your business.
1.What is your name?(Required.)
2.What is your Email address?(Required.)
3.What is your phone number?(Required.)
4.What is the name of your business?(Required.)
5.What is the Federal Employer Identification Number (FEIN) for your business?
6.What type of work does your business do?(Required.)
7.How many employees does your business employ?(Required.)
8.What is gross annual payroll for your employees?(Required.)
9.Who are the owner(s) of the business?(Required.)
10.Do the owners wish to be included or excluded from coverage?(Required.)
11.How many years have you been in business?(Required.)
12.Business location/mailing address(Required.)
13.How did you learn about Chesapeake Employers Insurance?
14.Do you have an insurance agent?(Required.)
15.Name of insurance agent and agency name(Required.)
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