MAG Mutual Insurance Agency, LLC Workers’ Compensation Quote For a free no-obligation quote fill out this form or call Chip Goen at 404-842-3311.

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? MailPhoneEmailFax (check all that apply) Have you spoken with a representative from our company?  YesNo 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:

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