You can also call us to get a quote by phone or to have any of your questions answered
888-900-9989
Day(s) Hours
Monday - Thursday 7:00 a.m. - 7:00 p.m.
Friday 7:00 a.m. - 5:00 p.m.
  • Pays for injury, sickness or death suffered by anyone of the job, regardless of fault
  • Protects employers from lawsuits from workplace accidents
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Business Name  Quote Needed By
   
Owners Name  Years Of Exp.
 
Address (No P.O. Box)  Fein/SSN
 
City  State  Zip  County
     
 Phone Number  Fax Number  Cell/Pager Number
   
Active E-mail Address
Preferred Method Of Contact
    Mail:    Fax:    Phone:    E-mail:  
Lic. # or App. Fee # Classification Entity (check one)

Partnership
Sole Owner
Corporation
Describe In Detail The Scope Of Your Company's Work/Operations with Class Code(s)
    Describe The Scope Of Your Employee's
    Work/Duties (Please Include Clerical/Office
    Related Duties If Any)
Estimated
Annual Pay
Pay Rate
($/hr)
# Employees
FT
PT
Do You Have a Current Worker's Comp Policy
Yes No
Exp. Date  
What Is Your Worker's Compensation Mod Factor (if known)  
Describe Your Worker's Compensation Loss History (if any)
How Many Years Have Your Carried Worker's Compensation Insurance   
Do You Have Any Work Exposure Outside Of California
Yes No
How did you hear about Skyles Insurance Agency?
    Construction Services    Economy Bonds Mail Flyer
    Post Card Friend Already a Customer
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    Other:  
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