Worker Comp Insurance
First Name
Last Name
Title
Company
Address
City
State
Zip
Telephone
Fax
E-Mail
Please
Confirm
E-Mail:
Web Page
Federal ID
Number
Current Workers
Comp Carrier
Number of
Employees
Experience
Mod. YES?
%

Please list the
annual payroll for
each employee
workers comp
class code.
Claim History
(Last 4 years)
Dan Burghardt Insurance
New Orleans East 504 241 7283 | East Bank 504 455 7283 | West
Bank 504 367 7283
New Orleans 504 821 3111 | St. Bernard 504 277 4000

Claims 504 456 8584 | Service 504 456 8585 | Fax 504 454 3988
Dan Burghardt Insurance

Office Locations
Canal St 504-821-3111 | Westbank 504-367-7283|Laplace 985-652-2000 | Kenner 504-455-7283
Metairie 504-455-7283

Services
Claims 504-456-8584 | Service 504-456-8585 | Fax 504-454-3988
Website Design and Internet Advertising Powered By
steven@scfwebsolutions.com
Copyright © 2008 Danburghardt , LLC All Rights Reserved
Welcome to Dan Burghardt Insurance
Contact us: 504-455-7283
or 1-888-376-6929