Workers' Compensation Insurance quote request.


To receive a quote for the program designed for you, please contact EPS Insurance at 707-526-2033, or fill out the online application below.

Please fill in all fields marked with an *

COMPANY INFORMATION/HISTORY          Step 1 of 4

* Name of business:

* Legal name of oranization:

* Street address:

* City:

* Phone number:

* Fax number:

* Name of key contact:

* Federal tax ID:

* Organization type:

Corporation
Partnership
Sole proprietor
Other

If "Other", please specify:

CLASSIFICATION INFORMATION

Select your industry:


Class code

Number of Employees

Estimated
Annual Payroll

Years in business:

Prior or current bankruptcies:

Yes   No

Prior policy cancellations:

Yes   No

If "Yes" to policy cancellations above explain:

Provide towing and or roadside assistance:

Yes   No

Product delivery using company vehicles:

Yes   No

If "Yes" to delivery above how many:

Member of CHLA or AAHOA:

Yes   No

Name of current carrier:

Estimated annual premium:

Policy anniversary date:

What is your current ExMod:

COMPANY OFFICER INFORMATION          Step 2 of 4

Name

Title

% Ownership

Workers Compensation Coverage?

Owner active in business:

Yes   No

Duties carried out:

Years of experience:

OPERATION & EMPLOYEE INFORMATION          Step 3 of 4

Gross annual sales:

Number of full time employees:

Number of part time employees:

Number of drivers:

Changes in operation during last 5 years:

Hours of operation:

Days per week:

Number of shifts:

Annual employee turnover percentage:

Number of locations:

Out of state exposure:

Yes   No

If "Yes" above, which state(s):

Company owned vehicles:

If "Yes" above, number of vehicles:

Are vehicles taken home:

Yes   No

Driving exposure:

Yes   No

If "Yes" to driving above, frequency of exposure:

MVR Pull Program:

Yes   No

Delivery driving radius:

HIRING PRACTICES          Step 4 of 4

Pre-employment physicals:

Yes   No

MVR check:

Yes   No

Drug testing:

Yes   No

SAFETY PRACTICESS

Specific medical provider for injured employees:

Yes   No

If "Yes" to above, medical provider name:

Frequency of employee safety meetings:

Frequency of equipment inspection and maintenance:

Is group medical offered:

Yes   No

If "Yes" above, number of enrollment:

Who is eligible:

All employees
Full time employees
Other

If "Other", who is eligible:

Current insurance carrier:

Current waiting period:

Is life insurance offered:

Yes   No

Is disability offered:

Yes   No

Is 401k or profit sharing offered:

Yes   No

Employer contribution:

Is paid vacation offered:

Yes   No

Is paid sick leave offered:

Yes   No

Is a return to light duty plan offered:

Yes   No

Is a return to full-time modified work plan offered:

Yes   No