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E-Mail:
info@fivestar
insuranceagency.com

Toll-Free Phone:
1-866-740-4132

Local Phone:
1-678-526-7979

Fax Number:
1-678-526-7222

Office Address:
2093 Rock Chapel Road
Lithonia, GA 30058

Five Star Insurance Agency

Owned and Operated by:
Aisha Smith-Danzy
Since 2006

Proudly Representing:

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Ins. Web Sales, Inc.


Georgia insurance quote

 
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:
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.)
 


 
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)
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class here:
$
 
 
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