IPSCO Workers’ Compensation Dividend Program -- Request for Quote


Yes! I would like to save money on my workers’ compensation insurance premium costs.
I do not want to ask “Why didn’t we participate?” when that first dividend is declared.

Contact Name:
 Firm Name:

Address 1:
 Address 2:

City:
 State:

Zip Code:
 Phone:

Fax:
 E-mail:

Average # of employees:
 My policy expires (Please give the date):

I authorize Insurance Planning & Service Company, Inc. to obtain the firm’s modification factor from NCCI.  
   
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