PLEASE ANSWER THE FOLLOWING QUESTIONS FOR YOUR
WORKER'S COMPENSATION QUOTE

1  
 
Contractors License/App Number Fein/SSN Quote Needed By
Business Name
Owners Name Years Of Exp.
Address (No P.O. Box)
City State Zip County
 
2  
 
Phone Number Fax Number Email Address
Please Contact Me By
Fax Phone Email
 
3
 
Describe In Detail The Scope Of Your Company's Work/Operations with Class Code(s)
 
4
 
Describe The Scope Of Your Employee's
Work/Duties (Please Inlcude Clerical/Office
Related Duties If Any)
Estimated
Annual Pay
Pay Rate
($/hr)
# Employees
FT
PT
1  
2  
3  
4 
5  
 
5  
 
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