For a Workers Compensation Quote call 1-800-421-6934
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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?:  
# of claims:  
Claim amt. pd $:  
Premium Amount:  
Policy Exp. Date:  
MOD Factor:  
Policy #:  
Describe the type of Coverage you currently have:  

Prior Carrier Info
Insurance Company Name:  
# of claims:  
Claim amt. pd $:  
Premium Amount:  
How many years with:  
MOD Factor:  
Policy #:  

About Your Business
# of Full-time:  
# of Part-time:  
Owner's Name:  
Fed Tax ID:  
License Type:  
Yrs in Business:  
License #:  
# of locations:  
Annual Gross Sales:  
Square Footage:  
Est annual payroll:  
Type of Business:  
Please describe your business here:  

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

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

General Information
Do you offer safety programs?
Do you offer health benefits to majority of employees?  
Do you employ any minors (under 18)?  
Did you purchase an existing business?  
Do you use subcontractors?  
Any travel beyond 100 miles?  
Any employees work from home?  
Any lapse in coverage during past 12 months?  
Any work above 15 feet?  
Had a bankruptcy in past 7 years?  
Are a member of any trade organizations?  

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 unitl you receive written notice.
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Offices throughout California |  License # OC04128  |  800-421-6934   |    carl@bayorr.com