Company Information

Please offer the full, legal name of your firm.


Your FEIN or TAX ID # will be 9 digits.




Physical Address
Contact Information




Prior Coverage 


Please estimate a date




Please upload a copy of your current policy if you have one on file. We do not need the entire policy. We would just need to first few pages, commonly labeled "declarations" or "information page" ... the pages we need will list the insured name & address, policy period, coverage, classification & rating schedule.

For however many years you've been in business, your insurance carrier(s) have maintained documented proof of workers comp related claims & losses throughout any given policy period. Any new carrier quoting your workers comp requires 4 years of currently valued loss runs (valued within 60 days of your current expiration date). If you are a new business venture, loss history is not mandated. If you would prefer signing a 'loss run request,' we can send this request to your insurance company and they can send us your loss history directly.
Rating Information

A workers comp class code is a 4-digit number that identifies an employee's classification of work. Whether they are roofers or clerical workers, each class code represents a specific level of risk for the insurance company.

# of full time employees

# of part time employees

Payroll is estimated. It's to your advantage to overestimate because your company will be audited at the end of each policy term (unless you have automatic payroll deductions).
General Information

Safety manual? Monthly meetings?













Remarks

Ownership Interest

Who holds stake in the company? In the state of CA, if you own more than 15% of a business, you have the option to exclude yourself from coverage. If you own less than 15%, you must be included in the annual payroll estimate.


Notes
Is there anything else you'd like to mention about your company, employees, operations, etc.?
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