Workers Compensation Quote - Short Form  * Indicates required information

* Year business started: Is this a seasonal business or one-time event?     Yes No * Approximate amount of workers compensation claims paid in the last 3 years: SELECT ---> None $500 - 999 $1,000 - 1,999 $2,000 - 2,999 $3,000 - 3,999 $4,000 - 4,9999 $5,000 - 7,499 $7,500 - 9999 $10,000 - 19,999 $20,000 - 29,999 $30,000 - 39,999 $40,000 - 49,999 $50,000 - 74,999 $75,000 - 99,999 $100,000 - 149,999 $150,000 - 199,999 $200,000 - 249,999 $250,000 - 324,999 $325,000 - 399,999 $400,000 - 499,999 $500,000 - 599,999 $600,000 - 699,999 $700,000 - 799,999 $800,000 - 899,999 $900,000 - 999,999 $1,000,000+ What is your business legal entity? SELECT ---> Corporation S Corporation Limited Liability Company Limited Liability Partnership Partnership Sole Proprietorship Limited Partnership Professional Corporation Nonprofit Corporation What industry is your company in? SELECT ---> OFFICE >>> Accountants/Bookkeepers Advertising Agencies Architects/Engineers Chiropractors' Offices Computer Consultants Consultants Doctors/Dentists/Medical Offices Dog Grooming Shops General Offices Graphic Designer Offices Inspection & Appraisal Services Interior Designers/Decorators Law Offices Management Consultants Manufacturers' Representatives Publishing Offices Real Estate Agents Travel Agents Veterinarians Other Office-based Industry SERVICES >>> Appliance Installation Appliance Repair Day Care Dental Labs Dry Cleaners Funeral Directors Locksmiths Musical Instrument Repair Nursing Homes Office Machine Repair Photocopying & Blueprinting Photoengraving Photographic Studios Pool Maintenance Printing (Commercial) Printing (Instant Print & Duplic.) Radio & TV (Retail & Repair) Rehabilitative Services Shoe Repair Tailors Taxidermists Tour Services Tow Trucks Tree Services Trucking Other Service-based Industry MANUFACTURING >>> Candy & Other Confec. Prod. Mfg. Canned Specialties Mfg. Computer Equipment Mfg. Electronics Mfg. Food Products Mfg. Household Audio & Video Equip. Mfg. Metal Mfg. Metal Working Job Shops Microbreweries Mfg. Office and Store Fixtures Partition and Shelves Mfg. Office Machines Mfg. Plastics Machines Mfg. Radio and TV Comm. Equip. Mfg. Tool and Die Patterns and Mold Mfg. Other Manufacturing-based Industry CONTRACTORS >>> Janitorial Services Air Conditiong Contractors Cabinet Building & Installation Cable Installation Carpentry Carpet Laying Installation Ceramic Tile Installation Commercial Fence Contractor Drywall Installation Contractors Electrical Wiring Contractors Floor Covering Installation Frame Contractors General Contractor Glass/Glazing Work Contractor Heating Contractors Landscaping Masonry Contractor Painting/Wallpapering Plumbing Contractor Residential Contractor Roofers Telephone Equipment Installation Other Contracting-based Industry RETAIL/WHOLESALE >>> Appliance Stores Automobile Dealerships Automobile Parts Bath Shops Bars Beauty Supplies Books/Magazines Retail Cameras & Supplies Candy/Nut & Confectionery Stores Carpet Retail Clocks Dance Clubs Drug Stores Electrical Supplies Florists/Garden Shops Gift/Souvenir Shops Greeting Cards Hardware Stores Health Food Stores Hearing Aids Hobby Shops & Model Stores Ice Cream Parlors Optical Goods Pet Shops & Pet Supplies Picture Frames Plumbing Supplies Restaurant Shoes Sporting Goods Tobacco Toys Trophies T-shirt Shops Video Tape Stores Other Retail/Wholesale Industry OTHER >>> Airboat Related Alarms/Guards Apartments Churches & Synagogues Coastal Property Habitat Horse Related Import/Export Marine Non-Profit Organization Oil & Gas Parks Water Related * Description of the nature of business:  (Please be as detailed as possible) * Describe the job function of employees:   Does your business offer health insurance to the employees?   Yes No  If Yes, Renewal  Month of Health Plan: Month 01 02 03 04 05 06 07 08 09 10 11 12 * Please list your most recent calendar year gross payroll: SELECT ---> under $100,000 $100,000 - 249,999 $250,000 - 499,999 $500,000 - 999,999 $1,000,000+

* # of Active Owners and/or Partners: --Pick-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+ Privacy: Our Promise We will use the information you provide to get you the best deal on Insurance. Your information will not be used for any other purpose. All information provided will be held in confidence. * # of Full Time Employees: --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+ * # of Part Time Employees: --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+ * # of Subcontractors: --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+   * # of Employees covered for workers compensation: --Pick-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+  * How many years of experience does the owner of your business have in your industry? --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+ Do you currently have workmans compensation coverage?    Yes No If yes, what company?  If yes, Expiration Date:  Do you have employees that live outside of your business's state?   No  Yes(specify the states): What is your NCCI experience modification factor? (If you do not have an experience modification factor, please enter N/A. If you don't know, enter "don't know") What is the desired liability coverage limit? SELECT ---> $100,000 $500,000 $1,000,000 $2,000,000 $3,000,000+ * When should your new coverage start? * What is your annual workers compensation premium range? SELECT ---> $500 - 999 $1,000 - 2,999 $3,000 - 4,999 $5,000 - $9,999 $10,000 - 19,999 $20,000 - 49,999 $50,000+

Other information your agent should know: * Name of Business: * First Name: * Last Name: Address: * City: * State: CA * Zip: * Phone: Fax: * Email: