WORKERS COMPENSATION WORKSHEET

 

First Name:

Last Name:

Business Name:

Address:

City:

State:

California

Zip Code:

Phone Number:

Fax Number:

E-Mail Address:

UNDERWRITING QUESTIONS

 

Please Describe the Nature of Your Business

 

Number of Owners:

Number of Employees:

Payroll of Owners:

Payroll of Employees:

Total Annual Gross Receipts: 

 

PAYROLL DETAIL INFORMATION

 

 

Class/Code

Payroll Rate

Annual Payroll

Employee Group 1

Employee Group 2

Employee Group 3

Employee Group 4

Employee Group 5

MISC INFORMATION

 

Years of Experience:

 

How Many Years Have You Operated This Business:

Business License Number:

License Type:

Is This Business Open 24 Hours A Day?

yes no 

Any Deep Frying (Food)?

yes no 

Is there Filing Of Propane Tanks?

yes no 

Current Insurance Company:

Current Annual Premium:

Misc Information
to help the agent 

 

LOSS INFORMATION

 

Losses-Claims in the last
5 years: 

 

 

If yes, date, amount paid and description of each loss-claim 

 

COVERAGE INFORMATION

 

Liability Limits Requested:

 

Please press the Submit Button ONCE.
Then wait for online confirmation of your request.
Thank you for your interest.