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  COVERAGES  


Workers Comp

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  
Workers Comp Insurance Quote

 Please complete the following general questionnaire. Our professional, courteous staff will contact you regarding your quote, or call us at (800) 779-PARS

Your Personal Data
Your Name:
Your Company's Name:
Street Address:
City:
State:

CALIFORNIA
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Rate Your Credit History and Past Insurance Payment History:
 (Some companies products are
based on your credit and payment history.) 		Excellent Fair
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 Currently Insured?
(If yes, list carrier, and # of years continuous. If none, type NONE)
 
 
 List Claims & Amounts Paid (If none, type NONE)
 
 
Do You Have Loss Runs and/or Experience Rate Mods.?
(If yes, please explain what documentation you have available:)
 
 
Years In Business:
 
 Business type: (proprietorship, corporation, etc.)
 
Underwriting Information:
 Describe IN DETAIL, Your Business Operations:
 
Payroll Class #1:
List Class Code # if you know it, and describe payroll class:
 
Insert Annual Payroll in dollars for this class here:
$
 
Payroll Class #2: (if none, leave blank)
List Class Code # if you know it, and describe payroll class:
 
Insert Annual Payroll in dollars for this class here:
$
 
Payroll Class #3: (if none, leave blank)
List Class Code # if you know it, and describe payroll class:
$
 
Insert Annual Payroll in dollars for this class here:
 
Send my quotation via: E-Mail Fax
Regular Mail
Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow Basic West Insurance Agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me the Quote NOW!
 

        

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