Request a California Workers Comp Quote

Detailed instructions for filling out Quick Quote Form are below.  You can also scroll over title for quick explanation.  California Workers Comp Quick Quote is generally turned around in 2-3 business days.  You can also download the more detailed Workers Comp Quote form in PDF.  Please fax or email to QuickQuote Processing at 888-758-2122.

 

Applicant Name

Mailing Address 

Years in Business 

Entity 

Fed TIN 

Locations 

1.
2.

3.

Proposed Effective Date 

 
Rating Information
   

 

      Categories, Duties, # of Employees Estimated Annual
State Loc# Class Code Code Descr Classifications Full Time Part Time Remuneration

 

Prior Carrier Information/Loss History 
Provide information for the past 5 years and use the remarks section for loss details.  Loss run will need to be sent by email or fax reference the applicant's name.
Year Carrier and Policy Number Annual Premium
Nature of Business/Description of Operations 
Give comments and descriptions of business operations and products:
Manufacturing--Raw Materials, Processes, Product, Equipment.  Contractor - Type of Work, Sub-Contracts.  Mercantile - Merchandise, Customers, Deliveries.  Service - Type, Location.  Farm-Acreage, Animals, Machinery, Sub-Contracts. 

 

Additional Notes/Clarifications  - brochures, loss runs, etc can be emailed referencing applicant name

 

 
Contact Information


Inspection/
Management
Name Phone Email

 

 
 

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