FAST AND EASY WORKERS COMP INSURANCE PROPOSAL FOR BUSY PEOPLE

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1

FIRST NAMEFirst Name

LAST NAME

BUSINESS NAMEyour full name

Today's Dateof appointment

Mailing Addressyour full name

Unit #your full name

Cityyour city

STATE

CA

ZIPZIP

CELL PHONECELL PHONE#

BUS PHONE

Emaila valid email

Email again for Accuracya valid email

CURRENTLY INSURED? If yes, list carrier and # of years continuous. If no current insurance, type "NONE"

UNDERWRITING INFORMATION

Type of Business

Type of Business?RetailOfficeRestaurantWholesaleMobileArtisan ContractorGeneral Contractor

Bus Structurepick one!

Business Stucture?Sole ProprietorPartnershipLimited Liability CorporationCorporation

# Locationspick one!

Number Locations?012345-1010-2020+

Annual Gross Revenues?Gross Revs

Total Number of Employees?

Total Number Employees?0-22-45-1010-2020+

Total Estimated Annual Payroll?your full name

Please describe exactly what your business does. Describe in full all products, services, and delivery methods your company offers.more details

0 / 250

List Class Code #1your full name

Annual Payroll for this Classyour full name

Briefly describe the work this class does.your full name

List Class Code #2Class code 2

Annual Payroll for this Class

Briefly describe the work this class does.your full name

List Class Code #3Class code 3

Annual Payroll for this Class

Briefly describe the work this class does.your full name

List Class Code #4Class Code 4

Annual Payroll for this Class

Briefly describe the work this class does.your full name

If there is more than one location, list the full address and what payroll classes & amounts are at each location.more details

0 / 500

List any additional information such as experience mods, safety associations you belong to, etc.your full name

Any Claims?Please describe in box to the right

YESNO

If there has been any claims, please list the claim date, amount paid, and a brief description of what happened. If you have had no claims, type "NONE".more details

0 / 250

CLICK HERE TO GET MY WORKERS COMPENSATION INSURANCE PROPOSAL

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By clicking the button below you agree to allow our agency to release this information, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. We take your privacy and data security very seriously!

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