Workers Compensation Insurance

Workers’ Compensation Insurance in California is a state program requiring employers to have an insurance policy covering employees for accidental work-related injuries. We offer competitive rates with “Pay as You Go” payment option program that enables businesses to buy Workers Comp Insurance with little or no money down.

Business name:

Business description:

Address:

City:

State:

Zip:

Telephone:

Fax:

Established date:

FEIN/SSN number:

Payroll estimate for the Year Beginning for the following codes

CodePayroll

description 1

code 2Payroll

description 2

code 3Payroll

description 3

Number of employees:

Excluded owners names

owner_name1

ownership 1

owner name

% of ownership

Type of business:

Business entity:

Prior insurance:YesNo

Requested effective date:

Is Health Insurance provided to employees:YesNo

Company name:

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