Wisconsin Workers
Compensation Insurance Quote
We provide comprehensive Workers Comp Insurance
services throughout northeastern Wisconsin!
The Insurance Shoppe of
Chilton, WI offers
comprehensive Commercial
Insurance coverage options
and experienced business
insurance services throughout
Wisconsin.
Contact us about Business
Owners, Auto, and
Contractors Insurance for
your Wisconsin business at
(920) 849-4534.
In addition to Wisconsin
Workers Comp Insurance, we
also offer affordable
Contractors Insurance plan
services.
The Insurance Shoppe
105 Southside Shopping Center
Chilton, Wisconsin 53014
(920) 849-4534
Toll Free: 1-866-601-1200
Fax: (920) 849-4158
We are your local Calumet County, Wisconsin insurance agency, offering
comprehensive workers compensation insurance coverage services to
businesses in the following cities and counties: Chilton, New Holstein,
Malone, Kiel, Hilbert, Forest Junction, Potter, Reedsville, Brillion,
Stockbridge, Sherwood, Hayton, Brothertown, Marytown, Calumetville,
Pipe, Johnsburg, Mt. Calvary, St. Cloud, Elkhart Lake, Ada, Sheboygan,
Cleveland, Manitowoc, Spring Valley, Osman, Plymouth, Two Rivers,
Whitelaw, Valders, St. Nazianz, Newton, Collins, Kimberly, Kaukauna,
Darboy, Oshkosh, Winnebago, Appleton, Menasha, Neehah, Menchalville,
Greenville, Holland, Little Chute, Wrightstown, Morrison, Wayside,
Kellnersville, Francis, Branch, Cooperstown, Maribel, De Pere, Bellevue,
Allouez, Ashwaubenon, Denmark, Tisch Mills, Kewaunee, Howard, Green
Bay, Oneida, Luxemburg, New Franken, Pilsen, Anston, Black Creek,
Freedom, New London, Sheyboygan Falls, Plymouth, Greenbush, Fond du
Lac, Peebles, Taycheedah, Kohler, Howards Grove, Dundee, Cascade,
West Bend, North Fond du Lac, Eden, Waldo, Cedar Grove, Hingham,
Fond du Lac County, Sheboygan County, Brown County, Winnebago
County, Outagamie County, and Manitowoc County, WI.
Business Name:    
Premises Address:
City:   Wisconsin
Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required) 

About Your Wisconsin 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 Wisconsin 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:


What types of coverages do you currently have:
Commercial Auto
Commercial Liability
Commercial Property
Workers Comp
Group Health
Group Life
Group Disability
Group Long Term Care
Other

Wisconsin 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 Information" button below to send your
Wisconsin Workers Compensation Insurance quote request.**

**Information received from this Wisconsin Workers Compensation Insurance
quote request form sent to The Insurance Shoppe, Ltd., 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 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 Wisconsin Workers Compensation Insurance Policy. We are
licensed in Wisconsin and will not provide quotes for other states.


Wisconsin Business Information:
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Wisconsin Workers
Comp Insurance Quote
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Working to insure and
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