California Worker’s Compensation Quote Your Name* Company Name* Type of BusinessIndividualPartnershipCorporationAssociationLabor UnionReligious OrganizationLimited PartnershipJoint VentureCommon OwnershipJoint EmployersLimited Liability CompanyTrust or EstateLimited Liability PartnershipGovernmental EntityOtherAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Enter Email Confirm Email Phone*Fax (optional)FEIN (Federal Employer ID #)(now required by all comp carriers to quote) Work Comp Rating InformationClass CodeClass DescriptionPayroll (annual)Number of Full Time EmployeesNumber of Part Time Employees Would you like to apply for credits on this account?NoYesCredits/DiscountsBusiness ExperiencePlease select number of years in business.01234567891011121314151617181920+Please select all that apply: Owner directly involved in day to day operations Drug testing of employees pre-employment Owner has minimum 10 years experience in the industry of business Formal accident investigation procedures in places Low supervisor to employee ratios (1 sup/12 or fewer employees) Return to work program in place Written safety program/policy Safety committee or designated safety manager Regular safety meetings held with employees Low employee turn over (under 10%) Benefits provided for employees Other OwnershipPartners, officers, relative (must be employed by business operations) to be excluded/included:NameTitle% OwnershipExcluded/Included? Previous InsuranceNo previous coverage1 year2 years3 years4 years5 years +Insurance HistoryPrior Workers Compensation Carrier Information: (please press + button on right to add rows for each year)Policy TermCarrier NamePolicy#Premium# of Claims Description of OperationsCommentsWe 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 checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. Yes, I Agree. Please Send Me a Workers Compensation Quote NOW!