**Information received from this Connecticut Workers Compensation Insurance
quote request form sent to the William Malloy Insurance Agency 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 workers compensation insurance policy plan 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 Connecticut Workers Compensation
Insurance policy. We are licensed in Connecticut and will not provide workers
compensation insurance quotes for other states.
We are your local Fairfield County insurance agency, providing Connecticut
workers compensation insurance coverage quotes in the following
Connecticut cities and counties: Stamford, Norwalk, Greenwich, Darien,
Riverside, Belltown, Springdale, Round Hill, Old Greenwich, East Norwalk,
New Canaan, Glenville, Byram, Cos Cob, Mianus, North Stamford,
Glenbrook, Wilton, Weston, Long Ridge, Noroton, West Norwalk, Westport,
High Ridge, Southport, North Wilton, Winnipauk, Cannondale, Turn of River,
South Wilton, Lyons Plains, Georgetown, Ridgefield, Branchville, Redding,
Topstone, Ridgebury, Redding Ridge, Branchville, Dodgingtown, West
Redding, Titicus, Hattertown, Bethel, Danbury, New Fairfield, Newtown,
Hawleyville, Botsford, Monroe, Bridgeport, Stepney, Shelton, Huntington,
Upper Stepney, Long Hill, Trumbull, Stratford, Easton, Fairfield, Greenfield
Hill, Stratfield, Nichols, Oronoque, Rivercliff, Devon, Lordship, and East
Bridgeport, New Haven, Hartford, Torrington, Waterbury, Meriden, New
Britain, New London, Norwich, Manchester, East Hartford, Suffield, Granby,
West Haven, West Hartford, Branford, East Haven, Hamden, Woodbridge,
Orange, North Haven, Groton, Rocky Hill, Newington, Wethersfield,
Glastonbury, Bloomfield, Blue Hills, South Windsor, Naugatuck, New
Hartford, Chesire, East Lyme, Old Mystic, Wallingford, Southington,
Middletown, Bristol, Laurel Beach, Litchfield, Pleasure Beach, Mystic, North
Westchester, Double Beach, Willimantic, Storrs, Canaan, East Windsor,
Vernon, South Canaan, Putnam, Guilford, Windham, South Britain,
Willington, Windsor, East Hampton, Brooklyn, Westchester, and everywhere
else in New Haven County, Litchfield County, Middlesex County, New London
County, Hartford County, Tolland County and Windham County, CT.
In addition to Workers
Compensation Insurance
for your Connecticut
business, we also offer
affordable Employee
Health Insurance plan
premiums or choose
another CT business
insurance coverage from
the list below.
Business Name:    
Premises Address:
City:     State:     Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required) 


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



# of full-time employees:    # of part-time employees:
# of locations:    Estimated Annual Payroll: $

Select all that apply to your Connecticut 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


Current Insurance Company: 
Policy #: Expiration Date: (mm/dd/yyyy)
What types of coverages do you currently have:
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Other


Other Insurance Company Used Within Past 3 Years: 
Policy #:
Losses past 3 years:
Description of losses or loss runs:



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


Principal             Name                                          Title                           Include
      1                   
      2                   
      3                   
      4                   
      5                   

Additional Information or Comments



Click on the "Submit Quote Information" button below to send your
Connecticut Workers Compensation Insurance quote request.**


Connecticut Business Information:
Connecticut
Workers Compensation
Insurance Quote
We provide affordable Workers Compensation Insurance to businesses in Connecticut!
Do you have questions about
workers comp insurance?
Request Connecticut Workers Comp Insurance Quote
Malloy Insurance Agency
Connecticut Business, Home, Health
& Car Insurance Specialists
Copyright 2004-2012
William Malloy Insurance Agency, Inc. - All rights reserved
William Malloy
Insurance Agency
87 Glenbrook Road
Stamford, Connecticut 06902
(203) 351-9898
Fax: (203) 351-9880
"Your Fairfield County
Connecticut Workers Comp
Insurance Agent"
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