Business Name:    
Premises Address:
Zip Code:
Contact Name:
Phone #:    Ext #:
Fax:    Years in Business:
Email Address: (Required) 

About Your Florida Business:

Federal Employer's ID #:
Description of Operations or SIC code:

# of full-time employees:     # of part-time employees:
# of locations:     Estimated Annual Payroll: $
Experience Mod (if any, per policy)

Select all that apply to your Florida business:
Operate or lease aircraft/watercraft     Work Underground
Work above 15 feet                           Require out of state travel
Use Subcontractors                            Delivery Service
Pre-employment physicals                   Offer safety incentive programs
Store, treat, dispose, or transport hazardour waste
Work on vessels, docks, or bridges over water

Recent Insurance Information:

Current Insurance Company: 
Policy #: Expiration Date: (mm/dd/yyyy)
Losses past 3 years:
Description of losses or loss runs:

Which insurance coverages do you currently have:
Florida Commercial Auto
Florida Commercial Liability
Florida Commercial Property
Florida Workers Comp
Florida Group Health
Florida Group Life
Florida Group Disability
Florida Group Long Term Care

Florida Employee Information:

Employee       Classification Code       Yearly Payroll Estimate
      1                                         $
      2                                         $
      3                                         $
      4                                         $
      5                                         $

Officers / Partners / Owners Information:

Principal             Name                                           Title                        Include

Additional Information or Comments

Click on the "Submit Quote Request" button below to send your
Florida Workers Compensation Insurance quote request.**

**Information received from this Florida Workers Compensation Insurance
quote request form sent to Optimal Insurance Group will be for our use
only and will not be sold, given to or distributed to any other parties. A quote
quote will be based on the Florida workers compensation insurance information
provided and does not guarantee acceptance of the risk by us. The precise
coverage afforded is subject to meeting underwriting guidelines, and the
terms, conditions and exclusions of the policy as issued. By submitting this
request you acknowledge that this is neither an offer to insure nor a
guarantee of insurance. Completion of this form does not entitle your
business to a Florida Workers Compensation Insurance policy. We are
licensed in Florida and will not provide workers comp insurance quotes
in other states.

Florida Worker Comp
Insurance Quote
We can provide comprehensive Florida
Worker Comp Insurance coverage services
in south Florida and throughout Florida!
Optimal Insurance Group of
Boca Raton, FL offers
comprehensive commercial
insurance coverage options and
affordable business insurance
services throughout Florida.
Contact us about Florida Group
Health, Commercial Auto,
Commercial Property, General
Liability, and Business Owners
Insurance at (561) 342-1695.
In addition to a Florida Workers
Comp Insurance quote, we also
offer affordable Group Health
Insurance policy quotes.
We are an independent Boca Raton, Florida insurance agency offering
worker compensation insurance quotes to mid-sized, large, and small
businesses in the following towns, cities and counties in south Florida:
Boynton Beach, Gulf Stream, Delray Beach, Lantana, Rainbow Lakes,
Atlantis, Lake Worth, South Palm Beach, Palm Springs, Greenacres,
Wellington, Haverhill, Palm Beach, Golden Lakes, Riviera Beach, Glen
Ridge, West Palm Beach, Lake Park, Royal Palm Beach, Jupiter, Coral
Springs, Fort Lauderdale, Parkland, Coconut Creek, Margate, North
Lauderdale, Lighthouse Point, Hillsboro Beach, Deerfield Beach, The
Hamptons, Highland Beach, Weston, Plantation, Playland Isles, Melrose
Park, Lauderhill, Sunrise, Tamarac, Wilton Manors, Oakland Park,
Lauderdale Lakes, Sea Ranch Lakes, Villages of Oriole, Pompano Beach,
Lauderdale-by-the-Sea, Boca West, Boca Pointe, Juno Beach, North Palm
Beach, Loxahatchee, Belle Glade, Palm Beach Shores, South Miami,
Cutler Ridge, Princeton, Perrine, Naranja, Homestead, Florida City, Leisure
City, Richmond Heights, Pinecrest, Howard, Coral Way Village,
Westchester, Westwood Lakes, Brownsville, Sweetwater, Key Biscayne,
North Bay Village, Miami Beach, Miami Springs, Virginia Gardens, Hialeah,
El Portal, Miami Shores, Medley, Indian Creek, Surfside, Bal Harbour,
North Miami, Biscayne Park, Pinewood Park, Opa Locka, Bunche Park,
Hialeah Gardens, Palm Springs North, Carol City, Norland, Ojus, Miami
Lakes, Biscayne Gardens, Hallandale, Sunny Isles Beach, Golden Beach,
Aventura, Uleta, Miramar, Pembroke Pines, North Miami Beach, Hallandale
Beach, Ives Estates, Pembroke Park, Coral Gables, Kendall, Dania Beach,
Cooper City, Davie, West Miami, Hollywood, Broward County, Martin
County, Miami-Dade County, and Palm Beach County, FL. We can also
offer Florida worker compensation insurance quotes throughout the
Sunshine state, including in Winter Haven, Lakeland, Miami, Orlando,
Tampa, St. Petersburg, Tallahassee, and Jacksonville, FL.
Florida Business Information:
Your Florida Worker Comp
Insurance Quote Connection
Optimal Insurance Group
4800 North Federal Hwy
Suite D-100
Boca Raton, Florida 33431
Palm Beach County FL
(561) 342-1695
Fax: 866-314-4026
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Florida Since 2002!
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