Workers Compensation
 
With complete and accurate information we'll be able to provide you the expert price quotation you, like hundreds of other the Western States contractors, should expect of us.
1. General Information
Contractor License Number:
Insured/Contact *
Company Name *
Phone *
 Fax
E-mail Address *
Policy Term Requested

   Address
MAILING
Street Address
City
State
 Zip
PREMISE
Street Address
City
State
 Zip
2.
Social Security # or Federal Tax ID#
3. Please indicate the type and amount of payroll you would like the quote based on
Job Class   Expected Annual
Payroll		   Hourly Wage
   
       
   
       
   
       

 
 
       
4. Have you had any worker's compensation claims?
If yes, provide dates & details
5. Do you have coverage currently?
If yes, provide loss runs from your prior carriers and include Company & Policy number:
How many years of continuous coverage do you currently
Indicate which type of business you operate
Please indicate all owners' names, date, and percent of ownership
Name


   Date of Birth


   % of Ownership
%
%
6. Number of years in business
years
If less than 4 years, numbers of years in the trade
7. Operations
Describe your operations

             
Percentage of New Construction:   Residential
%		   Commercial
%		   Industrial
%
             
Percentage of Remodeling:   Residential
%		   Commercial
%		   Industrial
%
             
Percentage of Repair work:   Residential
%		   Commercial
%		   Industrial
%
8. Number of employees
Full Time
   Part Time
   Seasonal
9. Comments

Enter Text Above: *
 
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License # 0D80851