Low cost New Hampshire insurance from Immanuel Insurance Agency
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Immanuel insurance Agency - NH Insurance



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On-Line Workers Comp
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal / Company Data:

Your Name:
Your Company's Name:
Street Address:
City:
State: (Must be New Hampshire)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again (for accuracy):
Phone:
Fax (optional):
 
OPT-OUT SELECTION: We realize your time is valuable. Rather than fill in all the underwriting information below, would it be easier to have us call you? If so, you can check the "Opt-Out" box above, press the send button at the bottom of this form, and have a friendly agent call you. If possible, please have your current policy handy as this has helpful information we may need.

If you want to continue the complete online quoting process, do NOT check the box and please continue below.

 


Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
 
List Claims & Amounts Paid
(If none, type NONE)
 
Years In Business:
 
Business type:
(proprietorship, corporation, etc.)
 
FEIN or Social Security #:
(now required by all comp carriers to quote)
 


 
Underwriting Information:
 
Describe IN DETAIL,
Your Business Operations:
 
Payroll Class #1:
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here:
$
 
Payroll Class #2: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here:
$
 
Payroll Class #3: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here:
$
 
 
Send my quotation via: E-Mail Fax
Regular Mail

 
Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a
Workers Compensation Quote NOW!


Click Button Below When Done

Please Click Only Once . . . May take up to 30 seconds!


Immanuel Insurance Agency | PO Box 300 | 3 Brittany Lane | Barrington, NH 03825
Phone: 603-335-4300 | Fax: 603-822-7101
Email: david@immanuelins.com | Office Map/Directions | About Us |
Privacy Notice | NH Insurance License #3356286

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