Workers Compensation No Obligation Quote Form

The Avsurance Workers Compensation Program is open to all aviation related risks subject to the following exclusions:

Risks located in monopolistic states: Nevada, North Dakota, Ohio, Washington, Wyoming and West Virginia
Risks with statutory comp premium of less than $3,000

You will be issued an individual premium quotation based on your specific underwriting data. If you choose to join the program an individual policy will be issued from the Insuror.

Please provide the following information:

After you have filled out the form, click the SEND button to submit it:

	Name of Insured (required)
	Street Address (required)
	City (required)
	State (required)
	Zip (required)
	Contact Person (required)
	Phone (required)
	Fax
	F.E.I.N.
	Current Insuror
	Policy Expiration Date
	NCCI Rating Bureau Number
	NCCI Modification Number
	Date Operations Began
	Under Current Management

Annual Payroll Data (as shown on current policy):
Class	Code	Payroll
Clerical NOC	8810
Pilots/Flight Crew	7422
A/C Ground Ops	7423
Other



If you are sending your application via mail or facsimile, please sign and send to : Mailing address: Avsurance Corporation, PO Box 1387, Ann Arbor, MI 48106-1387