Request For Workers Compensation Insurance Quote
   
Business (dba) Name of Company: Legal Name of Company:
Address:  City/State/Zipcode:
Phone Number: Fax Number:
Name of Key Contact: Federal Tax ID Number:
Type of Business:
Corporation         Partnership        Sole Proprietor         Other 
     
Classification Code:  # Employees: Est. Annual Payroll:
8046 Wholesale Auto Parts $
3828 Machine Shop $
8389 Repair/Garage $
8388 Tire Sales $
8810 Clerical $
Other: $
Other: $
   
How long in business? Any prior or current bankruptcies?
Any prior work comp policy cancellations? If so, why?
Do you provide towing and/or roadside assistance? Do you deliver products using company vehicles, how many?
Yes No
Yes No

 
Are you a current member of CAWA? Are you a current member of ASC
Yes No
Yes No
What is the name of your current carrier Estimated annual premium with current carrier
$
Anniversary Date Do you have an Experience Mod (ExMod)?
Yes No
What is your current ExMod  
 
       
Company Officer Information
 
Name Title %Ownership Comp Coverage?
%
%
%
%
 

Operation
     
Is owner active in business? Duties? Years Experience?
Yes No
Percentage of annual receipts that are wholesale? Gross Annual Sales  
% $  
How many Employees? How many employees are delivery drivers? Any changes in operations in the last 5 years?
Full Time Part Time
Hours of operation? How many days per week? How many shifts?
Percentage of annual employer turnover Do you have more than one location?  
%  
Any out of state exposure?    
Yes No
If yes, which states?
Any towing operations? Vehicles Owned? Taken Home?
Yes No
Yes No
Yes No
Any Delivery/Driving Exposure? Frequency MVR "Pull" Program?
Yes No
Daily Weekly Other
Yes No
Delivery Driving Radius    
50 miles or less 51 - 100 miles 101 - 250 miles 250+ miles
 
What percentage of your gross receipts are derived from delivery?  %  
Any repair work on RV’s and/or large commercial vehicles?   Yes No  
 
Hiring Practices
 
Pre/Post Physicals?  MVR Check?  Drug Testing?   
Yes No
Yes No
Yes No
     
Safety Practices
   
Do you use a specific medical provider for injured employees?
Yes No

 
How often do you hold employee safety meetings?
How often is your equipment inspected and maintained?
   
Miscellaneous
   
Is Group Medical provided?
Yes No
If yes, how many employees are enrolled?
Who is eligible?
All employees Full-time Employees Other  
Insurance Carrier
Waiting period
Do you offer Life Insurance?
Yes No
Disability Insurance?
Yes No
401K/Profit Share?
Yes No
Employer contribution towards benefits?
Paid vacation?
Yes No
Paid sick leave?
Yes No
Do you have a return to light duty plan?  
Yes No
Do you have a return to full-time modified work plan? 
Yes No
 


TO COMPLETE THIS FORM PLEASE DO THE FOLLOWING:

First, print a copy of this form for your records and for faxed submission with your Loss Runs by clicking the Print Button below:



Second, after printing your copy of this form, please click the Submit Button below to electronically send this form to CAWA Insurance Services for processing. You should hear back from us within 72 hours.

Third, please know that a firm quote for your coverage cannot be provided without submission of your currently valued loss runs for the past three (3) years. Please fax a copy of this form and three (3) years of currently valued loss runs to: 1-530-668-2779, Attention: Janice Armstrong.