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Full Corp 
Name: 

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Our preference is that you fax the first two pages of your Workers' Compensation, showing payroll and rates to: (914) 694-6004.

Or, please show the breakdown by classification. Refer to your current Workers' Compensation information page.

	Class Code	Payroll
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Current workers' comp. insurance carrier:
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If with the State Fund, are you enrolled in a Safety Group?:	No Yes

The Friedlander Group® will fax you back a quote within one business day. If you have any questions, please call us at (914) 694-6000. Thank you.

This website is provided for information only. It is not intended as a solicitation of insurance in any state other than New York.

Friedlander Group®, Inc.
2500 Westchester Ave., Suite 400A
Purchase, NY 10577
Phone: (914) 694-6000
Fax: (914) 694-6004
email: adamf@friedlandergroup.com