Name
Phone







6650 Reseda Blvd
Suite #108
Reseda, CA 91335

contact@gisinsure.com
WORKERS COMPENSATION INSURANCE
First Name:
Last Name:
Business Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
Who Referred You To Our Site?

Federal Employee
Identification Number:

UNDERWRITING QUESTIONS
 

Please Describe the Nature of Your Business

 

Number of Owners:
Number of Employees:
Payroll of Owners:
Payroll of Employees:
Total Annual Gross Receipts: 

 

PAYROLL DETAIL INFORMATION
 

  Class/Code Payroll Rate Annual Payroll
Employee Group 1
Employee Group 2
Employee Group 3
Employee Group 4
Employee Group 5

MISC INFORMATION
 

Years of Experience:

 

How Many Years Have You Operated This Business:
Business License Number:
License Type:
Is This Business Open 24 Hours A Day? yes  no  
Any Deep Frying (Food)? yes  no  
Is there Filing Of Propane Tanks? yes  no  
Current Insurance Company:
Current Annual Premium:
Misc Information
to help the agent 

 

LOSS INFORMATION
 

Losses-Claims in the last
5 years: 

 

 

If yes, date, amount paid and description of each loss-claim 

 

COVERAGE INFORMATION
 

Liability Limits Requested: