Workers Compensation Quote

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Business Name *

Contact Name *

Phone Number *

Location Address *

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Mailing Address *

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State

Zip Code

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Legal Entity *

Year Established *

EIN# or Social Security# *

Partner/Owners *

Owner Payroll *

Do you wish to Exclude Owners? *

Full-Time Employees *

Part-Time Employees *

Total Employee Annual Payroll *

Sub-Contractors *

Total Sub-Contractors Annual Payroll *

Annual Sales *

Current Class Codes – if known *

Desired Effective Date *

Current Carrier *

Expiration Date *

Please describe the nature of your Business *

Claims

Any Claims in the last 5 years? *

Date/Loss Amount *

Loss Details (Area) *

Date/Loss Amount (C2) *

Loss Details - Area (C2) *

What types(s) of business insurance are you interested in?

Additional Comments *

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American River Insurance Agency
333 University Ave
Suite 200
Sacramento, CA 95825
(888) 570-1058
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