Workers Compensation Quote Form Ledbetter Insurance Workers Compensation Form We would love to hear from you! Please fill out this form and we will get in touch with you shortly. 1 Personal Information2 Underwriting Information Type of BusinessSole ProprietorPartnershipLLCCorporationYour NameBusiness Name:Property Address:City:State:IllinoisIndianaIowaMissouriOhioWisconsinZip/Postal Code:Email:* Phone:Fax (Optional):Number of Years ExperienceNumber of Years in Business Date Coverage Needed: Date Format: MM slash DD slash YYYY Prior Carrier:Describe Business:Gross Annual Payroll:Number of Employees:Prior Claims?YesNoDescribe claims in detail:Limits and CoveragesLiability Limits$100/100/500$500/500/500Send my quotation via:E-MailFaxRegular MailCall me by PhoneContact InformationName* First Last Position*Best Method of Contact*PhoneEmailTextFaxPhone Number*Best Time to Contact* : HH MM AM PM EmailThis field is for validation purposes and should be left unchanged.
