Workers Compensation

CALIFORNIA WORKERS COMPENSATION INSURANCE

Workers Compensation Insurance is a form of insurance that can provide compensation / medical care for employees who are injured in the course of employment.

To receive a fast quote, please complete all of the fields on the form below and click “Submit”.

If you would rather complete the form off line, you can print the Workers Compensation Questionnaire. To receive a quote, please click here. Print the questionnaire, complete it, and fax or email it back to us.

Workers Compensation Questionnaire
* Required Fields
Owner's Name:*
Contact Name:*
Business Name:*
How Did You Hear About Us?*
Years In Business
Years Experience
Contractors License #*
License Class
Federal Employee Identification #*
Phone #*
Fax #*
E-mail*
Address - Mailing:
Address - Physical:*
Individual, Partnership, or Corporation
Please List All Owners And % Owned*
Current Insurance Company Name
Renewal Date
Year 1) Premium ($)
Year 1) Losses ($)
Year 2) Premium ($)
Year 2) Losses ($)
Year 3) Premium ($)
Year 3) Losses ($)
Year 4) Premium ($)
Year 4) Losses ($)
What Is Your Experience Modification Factor (If Any)?
What Trades Do Your Employees Perform?
Trade #1*
Total Payroll*
# Full-Time*
#Part-Time*
Trade #2
Total Payroll
# Full-Time
#Part-Time
Trade #3
Total Payroll
# Full-Time
#Part-Time
Trade #4
Total Payroll
# Full-Time
#Part-Time
Average Hourly Wage For Each Trade Listed Above?
Trade #1*
Trade #2
Trade #3
Trade #4
Estimated Annual Gross Receipts (Sales)*
Estimated Annual Subcontract Cost*
How Should We Deliver Your Quote?*
Additional Comments:
Security Code:* security_code
Please enter the above security code here
 

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