MTA Employer Services
Use this form to obtain a quotation.
Please provide ALL information requested, without it we are unable to develop a quotation.
Company Name
Federal ID (FEIN)
Contact Name
Contact phone Fax
Contact email Website
Business address
Number of employees Office > Field >
Year business established YYYY
Annual Gross Sales This year Last year
If you use a Payroll Service please check here and advise
Name of Payroll Service Annual Cost
IMPORTANT NOTE: Thank you for completing this request from. In addition to the information you have provided we also need you to fax to (305) 743-7328 or email to mail@marinetrades.com the following documents to us
Your most recent Workers Compensation insurance policy Declaration Page. This is the first page that shows your company name, address and type of business and the effective and expiry date of your coverage.
The policy rating schedule that shows the class code(s) and annual payroll projections for each class of employee. This will be close to the beginning of your policy.
Workers Compensation Loss Runs for the last 3 years. If you do not have them we can help you get them.
**The information collected from you is used to underwrite coverage and services. This information will be provided to others. Please read our Privacy policy for further information. By submitting this information to us you agree with the terms of our Privacy policy and generally accepted standards applicable to insurance agents and brokers regarding the submission of data to insurers, underwriters and service providers**
