Insurance Request Form

Company Name*
Contact Name*
First Last
Contact Phone*
Contact Email*
Business Address
Street Address Address Line 2 City State ZIP Code
Workers' Compensation Class Codes
Please list out your current class codes and corresponding payroll amounts. Click the + to add more.
Class Code Payroll Amount
Upload your current workers' compensation dec page.
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Upload your current experience mod worksheet
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Briefly describe your insurance needs

1128 Lincoln Mall, Suite 200, Lincoln, NE 68508
402-625-7246 | inquiries@unicogroup.com

Class Code	Payroll Amount