For a Workers Compensation Quote call 1-800-421-6934
Home | About Orr & Associates | Privacy | Contact Info | Questions? |





This information is kept confidential and not shared.

Please provide as much detail as possible, as this will influence the rates
and final cost OR call 1-800-421-6934 for assistance.

You may also wish to fax us your Declaration Page and Schedule Page
from your existing policy. Fax to 1-800-982-8955.

Workers Compensation Insurance Quote Form

Company & Contact Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
Fax:  

Current Insurance Information
Insurance Company Name:  
Any losses in last 3 years?:  

About Your Business
# of Full-time:  
# of Part-time:  
Fed Tax ID:  
Please describe your business here:  

Owners / Partner / Officers
Name
Date of Birth
Title
Ownership %

Payroll Information
Class Codes
Employee Duties
Annual Payroll $
Hourly Wage $

Additional Information:
Please provide any additional information that may be helpful in giving you an accurate quote or that you didn't have enough room for.
Note: By submitting this form you understand that no coverage is bound until you receive written notice.




Offices throughout California |  License # OC04128  |  800-421-6934   |    carl@bayorr.com