Workers’ Compensation Insurance

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Current Insurance Policy Expiration Date

MM

DD

YYYY

Desired Coverage

Minimum Coverage

Moderate Coverage

Best Coverage

Not sure

Other

I understand that insurance coverage is not bound or altered until I receive confirmation by an authorized representative of Great Shield Insurance Services LLC *

I agree