Workers compensation

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Class codes, payroll, entity type, owners, and ACORD-style underwriting answers help us prepare accurate workers compensation options from available carrier markets within minutes when eligible.

Applicant

CSLB #

Legal name FEIN Entity type Date business started Contact name Contact email Contact phone Desired effective date

Nature of business / operations

Location

Street City State ZIP

Class Codes and Payroll

Total estimated annual payroll: $0

Owners and Officers

Prior Coverage and Losses

Current carrier Current policy number Prior annual premium Experience modification

Loss history for the last 5 years

Underwriting

Work is performed by subcontractors or 1099 labor. Certificates are collected from subcontractors. Employees work above 15 feet. Employees perform underground work. Hazardous materials, blasting, or demolition exposure. Written safety program is in place. Employees are transported in groups. Seasonal or temporary employees are used.

Additional underwriting notes