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Workers Compensation Quote - California Only |
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* Year business started:
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* WC claims paid last
3 years:
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New Venture?
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Yes
No
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Buying an existing business?
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Yes
No
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Years of management experience in the field:
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Legal entity?
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* Business Description: (provide detail)
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* Describe the job function of employees:
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Classification Codes:
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Projected annual payroll for each code:
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# of Full Time Employees:
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# of Part Time Employees:
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Currently have WC coverage?
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Yes
No
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If yes, what company?
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Expiration Date:
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Out of State Employees?
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No
Yes
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Annual WC premium?
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Experience modification factor?
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(If you do not have an experience modification factor, please enter N/A. If you don't know, enter "don't know")
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Date Coverage starts?
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Other information your agent should know:
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| * Name of Business: |
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Contact Person First Name:
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Contact Person Last Name:
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Business Address:
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City:
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State:
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Zip:
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County:
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Phone:
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| Fax: |
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Email: |
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