Utilize our One-Step Online Quote Request Forms to get a pricing indication for your insurance need.



WORKERS COMPENSATION QUOTE
Please fully complete the following data form, and simply click the "Submit" button and we will contact you with an insurance quotation.

Please note we cannot accept binders or policy changes by email, only by phone during normal working hours.



WORKERS COMPENSATION INSURANCE

First Name:
Last Name:
Email Address:
Business Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Federal Employee Identification Number:
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.




17821 E 17th St, Suite 100, Tustin, CA 92780 :: LICENSE #0543173