Workers’ Comp Insurance Questionnaire (Secure Form)
If any questions, please contact us at (800) 750-2663.
Business name as listed on CSLB
*
Entity Type
*
Please Select
Corporation
Partnership
Individual/sole proprietorship
Federal Tax ID / EIN
Federal Employer Identification Number
Name of the person completing this form
Your E-mail Address
*
Contractors License Number (CSLB #)
*
If not available, enter NONE
Website Address
Phone Number
*
-
Area Code
Phone Number
Business Mailing Address
*
Where you receive mail
Business PHYSICAL Address Same as Mailing?
*
Yes
No
Description of business operation
*
What will employees be doing
Business PHYSICAL Address
*
Have you had prior Workers’ Comp coverage in the past five years?
*
Please Select
Yes
No
Upload current loss runs (claims history) for the past five years
Upload Files
Required to quote with the most of insurance companies
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Will your subcontracting exposure exceed 25% of your total gross sales?
*
No
Yes
Owner/Partner/Officer Info:
All current co-owners of the business must be listed
Owner's Name
*
First and Last Names of the business owner
Title
*
Ownership (%) of the business
*
Soc. Sec. # (SSN)
*
Has the applicant business declared bankruptcy in the last five(5) years?
*
Yes
No
Add Another Owner/Partner/Member?
*
Yes
No
Owner/Partner/Officer Info # 2:
Owner's Name
*
First and Last Names of the business owner
Title
*
Ownership (%) of the business
*
Soc. Sec. # (SSN)
*
Has the applicant business declared bankruptcy in the last five(5) years?
*
Yes
No
Add Another Owner/Partner/Member?
*
Yes
No
Owner/Partner/Officer Info # 3:
Please submit additional owners’ info in the comments box below
Owner's Name
*
First and Last Names of the business owner
Title
*
Ownership (%) of the business
*
Soc. Sec. # (SSN)
*
Has the applicant business declared bankruptcy in the last five(5) years?
*
Yes
No
Payroll Information:
Once quoted your premium will be based on the projected payroll figures provided. You may wish to be conservative in your payroll projections as once the policy is bound the payroll projections may not be amended. All policies will be audited at expiration.
(1) Trade/Class Code
*
(1) Estimated Payroll
*
Yearly
Hourly Wage
(1) Total number of Employees for the above trade/class code
*
Part-time
Fulltime
(2) Trade/Class Code
(2) Estimated Payroll
Yearly
Hourly Wage
(2) Total number of Employees for the above trade/class code
Part-time
Fulltime
(3) Trade/Class Code
(3) Estimated Payroll
Yearly
Hourly Wage
(3) Total number of Employees for the above trade/class code
Part-time
Fulltime
Comments
Upload current Loss Runs (Claims History) for the past five years
Upload Files
Most recent loss reports (claims history)
Cancel
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Contractors Brokerage Service Inc dba Capital Bonds & Insurance Services
By clicking Submit, I understand that NO COVERAGE IS BOUND until confirmed IN WRITING BY OUR AGENCY. Please be certain to forward current loss runs (claims history) if required. Questions? - please call us at (800) 750-2663.
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