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Email Us:
info@newbuffaloinsurance.com
Call Us:
(716) 332-1570
Text Us:
(716) 514-4040
Find Us:
20 E Tupper St Buffalo, New York 14203
About Us
Team Directory
Rate Us
Referrals
Our Blog
Accessibility
Insurance Products
Commercial Lines
Personal Lines
Home Insurance
Auto Insurance
Health Benefits
Risk Management
Client Services
Vehicle Change Request
Certificate of Insurance Request
Request A Proposal
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WC Referral Intake Form
Step
1
of
2
50%
Entity Legal Name
(Required)
DBA
FEIN
(Required)
Type of Entity
(Required)
Corporation
Individual
LLC
Not-For-Profit
Partnership
Mailing Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Is mailing address the same as physical address?
(Required)
Yes
No
Physical Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Do you need to add another physical address?
(Required)
Yes
No
Physical Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Contact Name
(Required)
First
Last
Contact Phone
(Required)
Contact Email
(Required)
Current WC Policy Information:
Carrier:
Effective Date:
MM slash DD slash YYYY
Annual Premium
Owners
Included
Excluded
Owners (Use the + sign to add additional Owners)
First
Last
Add
Remove
Payroll Provider:
Date of first processing with new provider:
MM slash DD slash YYYY
WC Exposure Information: (Use the + sign to add additional options)
Class Code
Annual Payroll Expense
Add
Remove
If the following documents are available, please upload: Dec Pages
Max. file size: 39 MB.
If the following documents are available, please upload: Recent Audit
Max. file size: 39 MB.
Current DBL/PFL Policy Information:
Carrier:
Effective Date:
MM slash DD slash YYYY
Annual Premium:
Employee Count: MALE
Employee Count: FEMALE
How many employees have wages over $89k?
Total annual payroll for employees with wages under $89k?
Referral Contact Information:
Name
First
Last
Phone
Email
Call
Email
About
Payments
