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Orr and Associates
Workman's Comp Quote-Request Form

So that we may better serve you, fill out as completly as possible.

Name
Telephone
Owners Name
Company Name
Current Policy Exp Date
Years in business
Current carrier
Any Claims in past 3 years
Fax number
Email
Address
Estimated Annual Payroll by classification.
Example:
Plumber more than $20. per hour
Carpenter less than $20. per hour
Painter more than $20. per hour
Office less than $20. per hour

We will contact you shortly with a quote.