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P I A M
860 Winter Street
Waltham, MA 02451-1414
toll free 800-522-7426
tel 781-434-7525
fax 781-434-6929
         

 
 

 Workers Comp Quote Request
Practice Name:
Location to be Insured:
Mailing Address:
City:
State:
Zip:
Contact Name:
Telephone:
E-Mail:
Fax:
Specialty:
Current Carrier:
Expiration Date:
Do you have any claims? Yes No
Gross Payroll of Employees (including physicians):
Number of Corporate Officers:
Gross Payroll of Corporate Officers:
Submit:
 
Disclaimer: Our online application forms are to provide current and prospective clients an indication of premium only. No coverage can be bound by this process. Hard copy, original signature, long form applications must first be obtained. Only after an insurance company has underwritten and provided written terms from this office can coverage be ordered.
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