WORKERS COMPENSATION QUOTE APPLICATION
Your Name
Your e-mail address
Your Business Name
Do you have workers compensation coverage now?
If you have coverage now, when does it renew?
Do you have an Employee Handbook?
How many employees have been hired in the last 12 months?
How many W2's were issued last year?
Do you transport or provide transportation for employees?
Do any employees work outside California?
Do you provide Group Health Benefits?
In the last 12 months, how many work comp claims have been filed?
In the last 24 months, how many work comp claims have been filed?
In the last 36 months, how many work comp claims have been filed?
List your employees and payroll

How often are your pay periods?

A full-Time employee works 30 or more hours per week
Job Category Full/Part Time How Many Payroll
 
 
 
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