We are prepared to provide you with a no cost, no obligation review and comparison of your insurance.

Workers Compensation
Quote Form

Your Name :
Business Name:
Street Address:
Address (cont) :
City:
State:	We only provide services in California
Zip/Postal code:
Work Phone:
Home Phone:
Mobile Phone:
Fax:
E-mail:
Contractor's License Type:
Number of Employees:
Hourly Employee Rate:
Employee Duties:
Estimated Annual Employee Payroll:
Do you have current insurance?	Yes No
Any claim in the last 3 years?	Yes No
If Yes, please explain:
Number of Years in Business:

For Direct Service Call:
800-347-6145

PO Box 1807
1123 Soquel Ave.
Santa Cruz, CA 95061

CA Lic.# 0757716

800-347-6145
831-423-5714 fax