Workers Compensation , Workers Comp Quote - San Jose Bay Area, California - Western Benefit Solutions

	Free Online Insurance Quotes

Call us today 408-278-8355

WORKERS COMPENSATION SURVEY

Complete the following information if you would like to obtain a Workers Compensation Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired. (All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.)

If you would like to print and fax the Workers Compensation Survey to us, please open up the Adobe Acrobat version. (Fields marked with * are mandatory)

Company Name:

* Phone:
(please include area code)

* Email:

* Website address:

* Contact name for inspections or questions:

* Address:

Address:
City:
State:	Zip:

Type of business:

Type of work performed, services provided, and product manufactured. Please provide a detailed description:

Name of owners/percentage owned/positions

Any safety program in effect? If yes, describe:

Do employees drive their own vehicles on Employer's business?

Any work under or above 15 feet?

Any seasonal employees?

Any employees younger than 16 or older than 60?

Any volunteers or donated labor?

Any employees with physical handicaps?

Any physical required after offering the job?

Any prior coverage declined, non renewed or cancelled?

Do you lease employees to others?

Do any employees work from home?

Number of locations?

What are your hours of operation?

Number of years experience in this field?

Projected Annual Revenue

Has the insured ever been in bankruptcy?

When would you like your new policy to take effect?

Class Code Employee Job Description	# of Employees Full Time or Part Time	Estimated Annual Payroll
		$
		$
		$
		$
If Corporation, please list Name	Title (included or excluded)	Payroll

Your current carrier: (so we don't quote same rates)
Current policy #:
Current policy exp. date:
Proposed effective date:
Prior coverage (carrier):
Prior coverage policy #:
Any claims?
Experience Mods?
Tax ID#:
Number of losses in last 3 years:
Number of years in Business:
Group Benefit Plans please select below Employer pays or more for ALL Employees Benefits provided only to management and supervisors No employer provided Health Care 401K/IRA/SEP Do you offer paid sick leave? Yes No Do you have general liability insurance? Yes No How did you hear about us?

Home About Us Contact Us Resources

WORKERS COMPENSATION SURVEY

Group Benefit Plans please select below