Affordable workers' compensation insurance quote

Mikkelsen Insurance Services

Information needed to quote Workers' Comp. Insurance! Please complete all blanks. California Only! In addition, please fax 3 years loss runs and a copy of your current Declarations page to 209-839-8632. If you do not have coverage at this time please call 800-444-3199.

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Client Information

Name:
Company Name:
Address:
City:	, California
Zip Code:
E-mail address:
Telephone:
Best time to call:
Years in business:
Company structure:	(Indiv. )(Corp. )(Partnership )
Taxpayer ID#:
License #:	Type:
Number of Employees:	Full time Part time
Annual Payroll:
Current Carrier:
Expiration Date:
Exp. Modification %:

Detailed description of operations:

Class Code	Job Description	Payroll for this Code

Claims Information

Number of claims last 3 years:	Amount paid:
Please give complete details, including dates: Please fax 3 years current loss runs to 209-839-8632.

Miscellaneous Information

Yes	No
		#1. Any lapse in coverage during last 3 years?
		#2. Any work performed underground or above 15 feet?
		#3. Does owner/manager have at lest 3 years experience in the trade?
		#4. Any work performed on barges, vessels, docks, bridge over water?
		#5. Any work subcontracted without certificates of insurance?
		#6. Is a formal safety program in operation?
		#7. Any prior coverage declined/canceled/non-renewed last 3 years?
		#8. Any employee-leasing or labor exchange of any kind?

Please give details to all yes answers and/or other information:

Please be sure that all questions are answered before you press "SEND". We are unable to respond to requests with incomplete information. If you prefer, print the form and fax it to 209-839-8632.