Workers Compensation Quote - UIS Georgia

Full Business Name (D/B/A)

Corporation Name

Owner Name

Owner Phone

Business Phone

Business Email

Years in this Location

Years in this Business

Contact Person

Contact Person Phone

Exact Nature of Business

Requested Effective Date

FEIN

Legal Entity

Mailing Address:

Street Name

City

State

Zip

County

Location Address(if different from above):
if same click here

Street Name

City

State

Zip

County

Annual Payroll

Number of Full Time Employees

Number of Part Time Employees

Employer Liability Limit(THIS IS NOT A MANDATORY FIELD)

Each Accident ($)

Disease Policy Limit ($)

Disease Each Employee ($)

Do you want to upload any document or file ?

(".txt", ".doc", ".docx", ".xls", ".xlsx", ".csv", ".pdf" files only)