Debbie Leek.com - Oregon and Washington Workers Comp insurance quotes. Fast Online OR and WA Workers Compensation Insurance Quotations - free OR and WA Workers Comp insurance quote form.

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We Gladly Accept:

Local Phone:
503-522-8208 (OR)
360-907-2096 (WA)

Fax:
888-458-6784

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Insurance-Web-Sales © 2009

On-Line Workers Comp Insurance Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal / Company Data:
Your Name:
Your Company's Name:
Street Address:
City:
Select State:
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again (for accuracy):
Phone:
Fax (optional):


Currently Insured? (If yes, list carrier, and # of years continuous. If none, type NONE)

List Claims & Amounts Paid (If none, type NONE)

Years In Business:

Business type: (proprietorship, corporation, etc.)

FEIN or Social Security #: (now required by all comp carriers to quote)


Underwriting Information:

Describe IN DETAIL, Your Business Operations:

Payroll Class #1:
List Class Code # if you know it, and describe payroll class:	Insert Annual Payroll in dollars for this class here:	$

Payroll Class #2: (if none, leave blank)
List Class Code # if you know it, and describe payroll class:	Insert Annual Payroll in dollars for this class here:	$

Payroll Class #3: (if none, leave blank)
List Class Code # if you know it, and describe payroll class:	Insert Annual Payroll in dollars for this class here:	$


Send my quotation via:	E-Mail Fax Regular Mail

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Debbie Leek Insurance Agency
Oregon Office: 4504 SW Corbett Ave., Suite 100 Portland, OR 97239
Phone: 503-522-8208 (Oregon) | 360-907-2096 (Washington) | Fax: 888-458-6784
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