Phalanx Industry Corporation

We offer a wide range of Flexible Policies in areas including:

Transportation

Automobile *
Motorcycle *
Trailers
Water Craft
Recreational Vehicles
Commercial Auto

Property

Homeowners Insurance *
Renter's Insurance *
Condo/Townhome content *
Personal Valuables
Commercial Insurance
Mortgage Protection
Cabins
Seasonal Properties *
Landlords Rental Property Insurance
Buildings

Life and Health

Life Insurance *
Health Insurance *

Commercial

Workers Comp.*
General Liability
Bonds

Annuitys

Please call (612) 735-7426 for more information.

* Free Rate Quotes Available

Workers Comp Form

Company Legal Name:
DBA:
Address:
Phone:
Fax:
Website:
Federal ID:
Type of Business:
Years in business:
Experience Modification Factor:

Do the employees currently receive paychecks?
Who currently processes the payroll?
What effective date doesthe company need?
Does the company currently have work comp. coverage?
Is the company's current coverage being non-renewed?
Who is the current workers' comp. insurance company?
Do you have a copy of the declaration page from their current policy?
What is the current estimated annual workers' comp. premium?
Select the liability limits the company would like quoted

Owner 1:			Owner 2:
Percent ownership:			Percent ownership:
Owner exempt:			Owner exempt:



Owner 3:			Owner 4:
Percent ownership:			Percent ownership:
Owner exempt:			Owner exempt:

Contact 1:			Contact 2:
Title:			Title:
Phone:			Phone:
Cell Phone:			Cell Phone:
Email:			Email:

Pay Frequency:
Pay Ending Day:
Pay Day:
Comments:

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For a FREE Specialized Quote, please call (612) 735-7426
E-mail us at quote@phalanxindustry.com