WCT Information Request

Please Fill out the form below if you are interested in joining the MMTA Workers' Compensation Trust. Someone will contact you shortly.
Company Name*
Contact Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Company Website
# Years in Business*
(with workers' compensation policy)
Current Insurer:*
Classcodes on your current policy
(NCCI 4-digit codes)
Current Premium (approximate)*
Current Policy Expiration Date*
MM slash DD slash YYYY
Brief description of your business:*

Please Fill out the form below if you are interested in joining the MMTA Workers' Compensation Trust. Someone will contact you shortly.