Atlantic Insurance Services

	Business
	Personal Auto
	Commercial Auto
	Workers Comp
	Homeowner
	Life
	Boat

Atlantic Insurance Services will give you what you pay for...insurance knowledge, insurance expertise and prompt service. Above all, we get paid to provide results - not excuses.
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Workers Comp Insurance Quote

General Information

Contact Name *
eMail *

Business Name
Address
City
State
Zip
County
Business Phone
Business Fax
Cell/Mobile Phone

Current Insurance Company

(not agency)

Company Name

Policy Expiration Date

Current Coverage

Business Information

Number of Full-Time Employees
Number of Part-Time Employees
Number of Years in Business
Number of Locations
Give a Brief Description of your business
Annualized Payroll
Limits Requested	100/500/100 500/500/500 1000/1000/1000
Describe any Claims in the past 5 years
Additional Comments

* indicates required fields

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.