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   WE'RE HERE TO SERVE YOU
   Midtown Insurance
   Group, LLC

   55 Church Street

   Prince Frederick, MD 20678

   PHONE: 301-899-6117
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   FAX: 301-899-8457

E-MAIL US AT:
jonesinsurance@aol.com

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 (Formerly: Jones & Associates
 Insurance Agency, Inc.
 6011 Allentown Road
 Camp Springs, MD 20746)

Jones Insurance guarantees your satisfaction on all your workers comp insurance products
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  Request a Workers Comp Insurance Quote - 24/7!
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.)
 
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
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