Business Name:    
Premises Address:
City:  
North Carolina
Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required) 

About Your North Carolina Business:

Federal Employer's ID #:
Description of Operations or SIC code:


# of full-time employees:     # of part-time employees:
# of locations:     Estimated Annual Payroll: $
Experience Mod (if any, per policy)

Select all that apply to your Cary, North Carolina area business:
Operate or lease aircraft/watercraft     Work Underground
Work above 15 feet                           Require out of state travel
Use Subcontractors                            Delivery Service
Pre-employment physicals                   Offer safety incentive programs
Store, treat, dispose, or transport hazardour waste
Work on vessels, docks, or bridges over water
Other

Recent Insurance Information:

Current Insurance Company: 
Policy #: Expiration Date: (mm/dd/yyyy)
Losses past 3 years:
Description of losses or loss runs:


Which insurance coverages do you currently have:
North Carolina Commercial Auto
North Carolina Commercial Liability
North Carolina Commercial Property
North Carolina Workers Comp
North Carolina Group Health
North Carolina Group Life
North Carolina Group Disability
North Carolina Group Long Term Care
Other

North Carolina Employee Information:

Employee       Classification Code       Yearly Payroll Estimate
      1                                         $
      2                                         $
      3                                         $
      4                                         $
      5                                         $

Officers / Partners / Owners Information:

Principal             Name                                           Title                    Include
      1             
      2             
      3             

Additional Information or Comments



Click on the "Submit Quote Request" button below to send your
Cary, North Carolina area Workers Compensation Insurance quote request.**


**Information received from this North Carolina Workers Compensation Insurance
quote request form sent to Ed Moore & Associates, Inc. will be for our use
only and will not be sold, given to or distributed to any other parties. A quote
will be based on the North Carolina workers compensation insurance information
provided and does not guarantee acceptance of the risk by us. The precise
coverage afforded is subject to meeting underwriting guidelines, and the
terms, conditions and exclusions of the policy as issued. By submitting this
request you acknowledge that this is neither an offer to insure nor a
guarantee of insurance. Completion of this form does not entitle your
business to a North Carolina Workers Compensation Insurance policy. We are
licensed in North Carolina and will not provide workers comp insurance quotes
in other states.


North Carolina Business Information:
North Carolina Workers
Comp Insurance Quote
We offer affordable North Carolina Workers Comp
Insurance policies in Wake County, NC and the
Cary, NC area for your small business!
Ed Moore & Associates, Inc.
103-B Kilmayne Drive
Cary, North Carolina 27511
Wake County, NC
Office: (919) 467-6339
Fax: (919) 467-6434

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Ed Moore & Associates of
Cary, North Carolina offers
comprehensive commercial
insurance coverage options
and experienced business
insurance services in the
Cary, NC area.
Contact us about North
Carolina Workers Comp,
Business Liability,
Commercial Auto, Builders
Risk, Professional Liability,
Property, and Group
Health Insurance for your
Cary, NC area small
business at (919) 467-6339.
In addition to a Cary, NC
area Workers Compensation
Insurance quote, we also
offer affordable Business
Liability Insurance policy
quotes.
Cary, N. Carolina
Area Business
Insurance Quotes
Workers Comp
Insurance Quote
We are a Cary, NC insurance agency offering North Carolina
workers compensation insurance quotes to small business in the
following towns, cities and counties in central North Carolina:
Raleigh, Morrisville, Apex, Garner, Green Level, New Hope, Neuse,
Bayleaf, Falls, Wake Forest, Forestville, Bethesda, Carpenter,
Lowes Grove, Auburn, Holly Springs, Chapel Hill, Durham,
Knightdale, Macedonia, New Hill, Brentwood, McCullers, Farrington,
Leesville, Durham County, Orange County, Chatham County, and
Wake County, NC.
( Wake County, NC Area )