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The Novak Agency
PO Box 460
Uniontown, OH 44685
Toll Free: 800-886-9021
Phone: 330-699-9021
Fax: 330-699-5355

Insuring Residents
and Businesses
In Ohio

Online Workers Compensation Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal / Company Data:
Your Name:
Your Company's Name:
Street Address:
City:
State:	MUST be Ohio!
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.)


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:	$


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