Our Workers Compensation programs:
All California employers must provide workers' compensation benefits to their employees under California Labor Code Section 3700. If you have 2 employees or 100+, we will find you the best rates. Among our carriers are companies such as: AIG, ACE, Safeco, Hartford, Zenith, Republic, Everest, C.N.A, State Fund, Applied Underwriters, Employers and others. We will find you coverage even if:

• Your mod factor is greater then 1.30
• You had lapses in coverage
• Your company is a new venture
• You have been declined everywhere else

Workers Compensation Questionnaire

General Business Information

Business Name: Business Entity: --- Select item --- Individual Partnership Corporation Join Venture Subchapter S-Corp Not for profit org LLC Owner's Name Owner to be --- Select item --- Included Excluded Percent of ownership: Street: City: State: Zip: Phone: Fax: Website: Years in business: New business: Yes No FEIN#: Mod. factor (if known) Years of continues Workers Compensation Insurance: If you are a contractor, enter your license# Estimated Gross Revenue Number of Full time employees: Number of Part time employees: Number of Seasonal employees: Total number of all employees: Total payroll How many rating classes do you have (such as Clerical, Sales, Managers) Code (if known. i.e 8810 for clerical) Classification Description (i.e clerical) Number of employees for this class Estimated annual payroll for this class Employee turn over is --- Select item --- Low Average High Brief Description of Business: Do you provide benefits to all employees eligible? --- Select item --- Yes No Do you have health insurance for your employees? --- Select item --- Yes No Do you pay sick leave? --- Select item --- Yes No Do your employees have paid vacations? --- Select item --- Yes No Do you have a written safety program? --- Select item --- Yes No

Previous Insurance History

For the year 2006   Insurance Company Expiration Date Premium Paid Number of Claims For the year 2005   Insurance Company Expiration Date: Premium Paid Number of Claims For the year 2004   Insurance Company Expiration Date: Premium Paid Number of Claims I need coverage: --- Select item --- ASAP Next Week Next Month I am shopping Do you need General Liability Insurance? Yes No Do you need Building Coverage? Yes No How did you hear about us?