Swain Insurance.com - Low cost GA Workers Comp insurance solutions for your Georgia Workers Compensation insurance needs, Fast GA Worker's Comp insurance quotes online.

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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:
State: (Must be Georgia)
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:	$


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James M. Swain & Associates, Inc. . PO Box 365 . Baxley, GA 31515
Toll Free: 800-870-5830 . Local Phone: 912-367-3601 . Fax: 912-367-7152
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