Workers' Comp

We would like to provide you with a free, no-obligation workers' comp insurance quote. Please complete ALL information so that we may provide you with a quote. This information will be kept confidential and will be used for quote purposes only.

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Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.

I understand that this does not constitute an actual "live" online quote, but is rather a submission of information to Head Insurance Group so that they may put together an insurance proposal (quote) for the above titled risk. There is no obligation on my part to purchase this insurance, and I understand that this online submission does not constitute a statement or contract for insurance.

 I have read and agree with the above disclaimer.
  (Box must be checked before request can be sent)

General Information
Name of Business:
Contact Name:
City:   State:   Zip:
Business Status:     Other:
Business Tax ID Number:
Business Phone:   Fax:
Best Time To Call:   AM   PM
Contact Email Address:

Current Insurance Information
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
NCCI #: NCCI Experience Modification #:
What type of coverages do you currently have:
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Group Health
Group Life
Professional Liability

About Your Business
# of full-time
# of part-time
How long
in business
How many
Estimated Annual
Please give a brief description of your business(below):

Employee Information.
Classification code
Estimate Yearly Payroll
Please list additional employees in the "Additional Comments" section below

Business Information
Please select all that apply to Business:
Operate or Lease aircrafts/watercrafts
Store, treat, dispose or transport hazardous
Work Underground
Work above 15ft.
Work on vessels, docks or bridges over
Require out of State travel
Use Subcontractors
Delivery Service
Pre-employment Physicals
Offer Safety and Incentive programs

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.

Before Submitting Your Information...
I understand that all of the above information MUST BE COMPLETED in order to obtain an Insurance Quote. Head Insurance Group will be unable to provide me an insurance quote if any fields above are left blank or are partially filled in. PLEASE re-check your information before submitting!

 I have read and agree with the above disclaimer.
  (Box must be checked before request can be sent)

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.


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Cedar Park
201 S. Lakeline Blvd. Ste. # 304
Cedar Park, TX 78613
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Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.

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