Workers Compensation Insurance Quote – California Services and Compass Services

Quote Request

Complete the following information if you would like to obtain a 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.

Personal Information
*First Name
*Last Name
Business Name
Business Address
City/St/Zip
*Phone Number
Alternate Number
*Email Address
Underwriting Information
What is the nature of your business?
Is the business a corporation, partnership, or sole proprietorship?	CorporationPartnershipSole Proprietorship
Number of Owners
Number of Employees
Payroll of Owners
Payroll of Employees
Total annual gross receipts
Business License Number
License Type
Years of experience
Years operated under current name
Other business names
Is this business open 24 hours a day?	YesNo
Any deep frying (food)?	YesNo
Is there any manufacturing, mixing, re-labeling or repackaging of products?	YesNo
Is there filling of propane tanks?	YesNo
Please describe ANY unusual exposures:
Payroll Detail Information
Employee Group 1
Class / Code
Payroll Rate
Annual Payroll
Employee Group 2
Class / Code
Payroll Rate
Annual Payroll
Employee Group 3
Class / Code
Payroll Rate
Annual Payroll
Employee Group 4
Class / Code
Payroll Rate
Annual Payroll
Employee Group 5
Class / Code
Payroll Rate
Annual Payroll
Claims Information
Were there any losses or claims in the last 5 years?	YesNo
	If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company
How much are you paying now?
What is the liability limit requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote	MorningAfternoonEveningAnytime	Or Specify Other:

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Quote Request

Personal Information

Underwriting Information

Payroll Detail Information

Claims Information

Coverage Information