Business Name:    
Premises Address:
City:  
Arizona
Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required) 

About Your Arizona Business:

Federal Employer's ID #:
Description of Operations or SIC code:


# of full-time employees:     # of part-time employees:
# of locations:     Estimated Annual Payroll: $
Experience Mod (if any, per policy)

Select all that apply to your Arizona business:
Operate or lease aircraft/watercraft     Work Underground
Work above 15 feet                           Require out of state travel
Use Subcontractors                            Delivery Service
Pre-employment physicals                   Offer safety incentive programs
Store, treat, dispose, or transport hazardour waste
Work on vessels, docks, or bridges over water
Other

Recent Insurance Information:

Current Insurance Company: 
Policy #: Expiration Date: (mm/dd/yyyy)
Losses past 3 years:
Description of losses or loss runs:


Which insurance coverages do you currently have:
Arizona Commercial Auto
Arizona Commercial Liability
Arizona Commercial Property
Arizona Workers Comp
Arizona Group Health
Arizona Group Life
Arizona Group Disability
Arizona Group Long Term Care
Other

Arizona Employee Information:

Employee       Classification Code       Yearly Payroll Estimate
      1                                         $
      2                                         $
      3                                         $
      4                                         $
      5                                         $

Officers / Partners / Owners Information:

Principal             Name                                           Title                        Include
      1             
      2             
      3             

Additional Information or Comments



Click on the "Submit Quote Request" button below to send your
Arizona Workers Compensation Insurance quote request.**


**Information received from this Arizona Workers Compensation Insurance
quote request form sent to Arizona Insurance Clinic will be for our use only
and will not be sold, given to or distributed to any other parties. A quote will
will be based on the Arizona workers compensation insurance information
provided and does not guarantee acceptance of the risk by us. The precise
coverage afforded is subject to meeting underwriting guidelines, and the
terms, conditions and exclusions of the policy as issued. By submitting this
request you acknowledge that this is neither an offer to insure nor a
guarantee of insurance. Completion of this form does not entitle your
business to an Arizona Workers Compensation Insurance policy. We are
licensed in Arizona and will not provide workers comp insurance quotes
in other states.


Arizona Workers Comp
Insurance Quote
Arizona Insurance Clinic of
Tucson, AZ offers
comprehensive commercial
insurance coverage options and
affordable business insurance
services throughout Arizona.
Contact us about Arizona
Commercial Auto, Commercial
Property, Builders Risk,
Workers Compensation, and
Small Business Liability
Insurance at (520) 323-6887.
In addition to a Arizona
Worker Compensation
Insurance quote, we also offer
affordable Commercial
Property Insurance plan
quotes.
We are a Tucson, AZ insurance agency offering cheaper Arizona
workers compensation insurance rate quotes for your large or
small business located in the following cities and counties
throughout the Grand Canyon state of Arizona: Oro Valley, South
Tucson, Cortaro, Vail, Sahuarita, Benson, Sonoita, Elgin, Green
Valley, Sierra Vista, Continental, San Xavier, Madera Canyon,
Patagonia, Nogales, Tubac, Amado, Carmen, Pan Tak, Rillito,
Redington, Marana, Red Rock, Picacho, Oracle, San Manuel, Mt.
Lemmon, Catalina, Mammoth, Eloy, Casa Grande, Arizona City,
Coolidge, Florence, Gilbert, Peoria, Glendale, Sun City, Maricopa,
Sun Lakes, Chandler, Mesa, Scottsdale, Sun City West, Tempe,
Phoenix, Apache Junction, Surprise, Cochise County, Santa Cruz
County, Graham County, Pinal County, Maricopa County, and
Pima County, AZ. We can also offer your small business an
affordable Arizona workers comp insurance quote in the cities of
Flagstaff, Prescott Valley, Yuma, Lake Havasu City, Sedona,
Bullhead City, and Prescott, AZ.

Arizona Business Information:
Your Arizona Workers
Compensation Insurance
Quote Source
Arizona Insurance Clinic
4925 5th Street
Suite 101
Tucson, Arizona 85711
Pima County AZ
(520) 323-6887
Fax: (520) 323-9665
We can provide lower cost Arizona Workers
Compensation Insurance coverage for your Tucson, AZ
area small business and throughout Arizona!
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