Raritan Agency saves money for you on your New Jersey personal and business insurance
Raritan Agency
Insuring New Jersey Residents and Businesses.                 |  Home  |  Email Us  |
754 Route 18, Suite 101
East Brunswick, NJ 08816

   About Raritan Agency    Personal Insurance    Business Insurance    Service   


 
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: (Must be New Jersey)
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
Regular Mail

 
Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a
Workers Compensation Quote NOW!


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We are Here to Serve You - Find out more about Raritan Agency!

CONTACT US

Raritan Agency, Inc.
754 Route 18, Suite 101
East Brunswick, New Jersey 08816

Phone: (732) 238-6060
Fax: (732) 390-0764

Email Us: info@raritanagency.com
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