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MAG Mutual Insurance Agency, LLC

Workers’ Compensation Quote

Contact Information Practice Name: # Employee Years in Business: MD(s) Name: Type of Business: Corporation Partnership Sole proprietorship Other Mailing Address: City:     State:      Zip: Location #1: City:      State:      Zip: Phone:   Fax: Email Address: Worker's Compensation Effective Date: Current Carrier: Estimated Annual Payroll: Number of Corporate Officers/Partners: Any Losses: How do you wish to be contacted? Mail Phone Email Fax (check all that apply) Best time to be contacted during working hours? Have you spoken with a representative from our company?   Yes No If so, who? How did you hear about us? Web site / Search Engine Direct Mail Tradeshow Newspaper / Magazine MAG Mutual Employee Colleague Other   If other, please explain:   Requested information Information collected on this page will not be divulged or distributed to any individual or organization outside of MAG Mutual Insurance Company or the MAG Mutual Group of Companies without your express permission, or as required by law.