Workers Compensation 

Worker's Compensation Application
When an employee suffers a work related injury or illness, workers compensation insurance steps in to provide benefits based on the type of illness or injury sustained. Workers compensation is based on a no-fault system, which means that an injured employee does not need to prove that the injury or illness was someone else's fault in order to receive workers compensation benefits for an on-the-job injury or illness.
As a California and Nevada employer you are required under California Labor Code Section 3700 to provide workers compensation benefits for your employees. You can purchase workers compensation insurance from a licensed insurance company or through the State Compensation Insurance Fund (SCIF). Employers may also have the option to self-insure. Your broker-agent can assist you with purchasing workers compensation insurance from a licensed insurance company and can assist you with information on SCIF and self-insurance.

1. General Information
Contractor License Number:
* Insured/Contact Name
* Company Name
* Phone
 Fax
* E-mail Address
Policy Term Requested
Mailing Address
* Street Address
* City
* State
 * Zip
 
Premise Address
Street Address
City
State
 Zip
* Social Security # or Federal Tax ID#
2. Payroll excluding Owners, Officers & Clerical
Job Class   Expected annual Payroll   Hourly Wage
   
       
   
       
   
       
   
       
4. Have you had any worker's compensation claims?
If yes, provide dates & details
5. Do you have coverage currently?
If yes, provide loss runs from your prior carriers and include Company & Policy number:
How many years of continuous coverage do you currently
Indicate which type of business you operate
Please indicate all owners' names, date, and percent of ownership
Name

   Date of Birth

   % of Ownership
%
%
6.Number of years in business
Years
If less than 4 years, numbers of years in the trade
Years
7. Operations
Describe your operations

             
Percentage of New Construction:   Residential
%		   Commercial
%		   Industrial
%
             
Percentage of Remodeling:   Residential
%		   Commercial
%		   Industrial
%
             
Percentage of Repair work:   Residential
%		   Commercial
%		   Industrial
%
8. Number of employees
Full Time
   Part Time
   Seasonal
9. Comments


 

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LICENSE #: OD80851

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Last Updated Monday, September 8, 2008
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