Workers' Compensation Quote Request

California law requires workers' compensation for any business with employees. It pays medical treatment and replacement wages when someone is hurt at work, and protects you from being sued over that injury.

Fill in what you know and leave the rest blank — only your name, email and phone are required. We will come back to you for anything missing. Nothing here is an application and nothing is binding.

What Workers' Compensation covers

Your business Business Name

DBA / Trading AsOnly if different from the name above.Business Structure

Business Address

CityZIP Code

Mailing AddressOnly if your mail goes somewhere else.

Your First NameYour Last Name

Email AddressPhone Number

Years in BusinessApproximate Annual RevenueA rough figure is fine.

WebsiteIf you have one.

Your people and operations Describe Your Business Operations Job Roles, Headcount and Payroll

Any Employees or Work Outside California?If Yes, Which States?

Any Employees Working From Home?Do You Use Subcontractors Without Their Own Cover?

Your history

Experience Modification RateA number your current insurer assigns based on your claims record. Leave blank if you do not know it.

Your current cover and timing Any workers' compensation claims in the past 5 years?

Current or Previous InsurerIf you are switching or renewing.What You Pay NowIf you know it.

When Do You Need Cover to Start?

Anything Else We Should Know

This is a solicitation for insurance. Completing this form does not apply for or bind cover. Coverage cannot be bound or changed via this form, e-mail, voicemail, text, or facsimile — only by written confirmation from our office.

Would you rather fill it in on paper?

Download the same questions as a printable form, or as a Word file you can type into, and bring it in or send it back to us.

PDF version · Word version · All quote request forms

Would you rather fill it in on paper?

Rather just talk it through?