Neill and Neill Insurance Agency Inc.

662 Riverdale St, West Springfield, MA 01089

 
 

Workers Compensation Form

Every state requires employers to compensate workers for injuries caused by on-the-job accidents or diseases. Many general contractors are also requiring sub contractors to purchase Workers Compensation even if the sub has no employees.

For a Quote please complete the following or fax a copy of your current policy with 5 year loss runs and experience modifications calculation sheets.

 

Full Name:*
Title
Organization
Address*
City*
State*
Work Phone Number:*
Fax Number:*
Email Address*
Website:
Policy Renewal Date*
Best Time To Call*

Required [*]