Business Information

Business Name:

Premises Address:

City:

NORTH CAROLINA

Zip Code:

Years In Business:

Contact Name:

Phone:

Extension #:


Email:  (Required)


How Best To Contact You:



Federal Employer's ID #:

Description of Operations:


# of full-time employees:


# of part-time employees:


# of locations:


Estimated Annual Payroll:
$

Experience Mod (if any, per policy):




Liability Information
(Select all that apply to your 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 hazardous waste
Work on vessels, docks, or bridges over water
Other



Recent Insurance Information

Current Insurance Company:


Insurance Expiration:


Any losses past 3 years?


Description of losses, including
amount paid on each accident.




Workers Compensation Information

Classification Code #:


Yearly Payroll Estimate for
Classification Code Above:



Classification Code #:


Yearly Payroll Estimate for
Classification Code Above:




Classification Code #:


Yearly Payroll Estimate for
Classification Code Above:




Classification Code #:


Yearly Payroll Estimate for
Classification Code Above:




Classification Code #:


Yearly Payroll Estimate for
Classification Code Above:




Officers / Partners / Owners Info

Include officers, partners, and
owners in workers compensation:





Click the "Submit Quote Request"
button below to send your North
Carolina Workers Comp Insurance
request to Ed Moore & Associates.


***By submitting this request you
acknowledge that this is neither
an offer to insure nor a guarantee
of insurance.***








We are a Cary, NC insurance agency
offering North Carolina workers comp
insurance quotes in the following cities
and counties in central North Carolina:
Raleigh, Morrisville, Cedar Fork, Apex,
Garner, Swift Creek, Green Level,
New Hope, Neuse, Bayleaf, Falls,
Wake Forest, Forestville, Bethesda,
Carpenter, Lowes Grove, Auburn,
Holly Springs, Chapel Hill, Durham,
Oak Grove, Knightdale, Macedonia,
New Hill, Brentwood, McCullers,
Farrington, Leesville, Durham County,
Orange County, Chatham County, and
Wake County, NC.
North Carolina
Workers Compensation
Insurance Quote
Wake County, NC Area
Ed Moore & Associates, Inc.
© 2011, All Rights Reserved
919-467-6339
Since 1971
Always here when you need us. Protecting
hundreds of North Carolina families and businesses.
ED MOORE
& Associates, Inc.