WORKERS COMP

 

Please fill out the form below to request a quote. 

Items with * are required fields
   
Contractor License Number:*
License Class*
Business Name:*
Business Address:*
City:*
State:
CA
Zip:*
Owner/Contact Name:*
Business Phone:*
  Mobile Phone:
  Business Fax:
Business Email:*
Estimated Annual Employee Payroll:*
$
   
Number of Employees:*
Number of Active Owners:
List Examples Of Jobs:*
   
FEIN #:
   
Social Security # of Partners
(Sole owner, each partner, or each officer on license)
   
Prior Worker's Comp Carrier
(please fax current Value Loss Runs - dated in the last 30 days)
   
Prior Worker's Comp Policy Number:
   
Do You Have a Formal Safety Program?:*
Yes     No
   
Any Claims Under Workers Comp?:*
Yes     No
 
 
How Often Are Your Safety Meetings?:*
   
Any Disciplinary Actions to Your License?:*
Yes     No
 
 
Any OSHA Citations?:*
Yes     No
 
 
Any Bankruptcies in the Last 7 Years?:*
(if so, provide copy of discharge)
Yes     No
   
Detailed Description of any Yes Answers:
 
 
How Did You Find Us? *
Flyer in the mail   
Online search
Referral
Other (If checked, please specify:)
 
 
   

 

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