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General
Information |
| Name of business: |
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| Contact name: |
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| Address: |
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| City: |
State:
CA Zip: |
| Business status: Individual, Corporation, Partnership, Joint
Venture, or Other |
|
| Your business Tax ID or SSN number: |
|
| Business phone: (w/area) |
Fax:
(w/area) |
Best time to call:
(a.m./p.m.) |
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| Contact email address: |
|
| Years in business |
|
| How many employees? |
What is your monthly payroll?
|
| Safety program in force? Yes or No |
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| Are you presently insured? Yes or No |
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| Name of current insurer: |
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| Current annual premium: |
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| Policy period: |
To |
| Short description of business operations: |
|
| Do employees perform work at heights above 15 Feet? Yes or
No |
|
| What is your company's experience mod
factor? |
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| Please tell us some information about any claims listed
above. |
|
|
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