Hickey-Finn & Company, Inc.
Workers Compensation and
Employers Liability Insurance Quote

The information collected in this form will be used
only to provide you with a speedy insurance quote,
and will not be shared with any other parties.

* Business Name:  
* Business Contact Person:

    Federal Tax ID Number       or NYSUI Number  

    Address:  
    City:      State:    Zip Code:
* Phone Number / Ext. :  /    Fax Number:
* Best Times to Call: 
* E-mail:
* Indicates Required Fields
Years in Business:    Experience Modification:


Describe Your Business:
Amount of Payroll
Class Code/Description
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11.
Do you currently have coverage?   
Have you had coverage during the last 3 years?     

If YES,
Please provide loss runs for the period up to and including the last 3 years.
Note: Loss Run information can be provided by your prior agent/company.


 

Thank You!