WORKERS' COMPENSATION INSURANCE
QUOTATION INFORMATION SHEET

Please fill out the following information sheet as completely as possible, so we can provide you with a free and competitive quote for your insurance.

Business Information

Name/DBA:
Telephone Number:
Fax Number:
Business Address:
City:
State: CA only
ZIP:
* E-mail:
Web Site URL:

Business Description
Number of Years in Business:
Business Nature:
Federal Employer ID Number:
Employers Liability Limit: $1,000,000
Each Accident: $1,000,000
Policy Limit: $1,000,000
Description of Business Operations:

Individual Included/Excluded
Employee
Name
Date mm/dd/yy
Title
Ownership %
Duties
 
1  Include  Exclude
2  Include  Exclude
3  Include  Exclude
4  Include  Exclude
5  Include  Exclude

Prior Carrier Information
Year:
Carrier:
Policy #:
Annual Premium:
# of Claims:
Loss Amount Paid:

General Information
Answer each of the following questions either "yes" or "no." Explain all "yes" answers in the box provided below.
 
 
YES
NO
Does applicant own, operate or lease aircraft/watercraft?
Is applicant engaged in any other types of business?
Any part-time or seasonal employees?
Any prior coverage declined/canceled/non-renewed?
Any employees under 16 years of age?
Any employees over 60 years of age?
Is a formal safety program in operation?
Are physicals required after offers of employment are made?
Any volunteer or donated labor?
Are employee health plans provided?
Are athletic teams sponsored?

Comments
 
 

Employee Information
Employee Classification
# of Employee
Annual Payroll
Clerical    
Warehouse    
Sales Person    
Management    
     
     
     
     

Employee Benefits

Average number of employees excluding officers, partners, and sole solicitors:

Full Time   Part time

W-2’s issued last year :

Average starting wage (per month):

Average wage (per month):

Company paid benefits (check all that are applicable):

Health Disability Sick leave Leave Union Other
 

Management

Number of years experience of management?

Is this business owner managed? Yes No

Designated medical provider:

If workplace is bilingual, are supervisors bilingual? Yes No

Are supervisors accountable for safety? Yes No

 

Employee Selection & Workplace Safety
Check all that are applicable
Written employment application
Written orientation program
Written discipline procedure
Early return to work program
Safety incentive program
Pre-employment physicals
Drug screening
Reference checks
MVR checks
Use of personal protective equipment enforced
Exposures control
 

Claims History
If there have been claims in any of the following categories, please indicate and explain in the comments box below.
Losses over $25,000
Psychological stress
Accidents involving multiple employees
Harassment/Wrongful discharge
Attacks/Physical violence against employees
Cumulative/Repetitive trauma
Employer’s liability
Please explain any claims in the comment box below: