Workers Compensation Insurance. Low Cost


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Workers' Compensation Insurance

Get Free Workers' Comp Insurance price quotes

Worker's Comp coverage is REQUIRED by California State Law.

Workers Compensation Insurance protect employers from lawsuits resulting from workplace accidents covers medical expenses and lost income of your employees if they are injured in the course of performing work-related activities. Workers compensation insurance covers workers injured on the job, whether they're hurt on the workplace premises or elsewhere, or in auto accidents while on business. It also covers work-related illnesses.

Ancona Insurance understands the special needs for work compensation insurance of businesses and tailors our services to meet your workers compensation insurance needs.

• Get rate quotes on insurance plans for small, medium and large employee groups
• It's FREE and easy to use

Why do I need it?

California law REQUIRES every employer to carry Worker's Comp insurance on their employees, even if they are part-time. Employers who do not comply with these regulations can face heavy fines and penalties, which can be detrimental to your business.

Contact Information
Name
Company Name
Contact Name
Street address
City
State
Zip Code
Contact Phone	Ext.
FAX
E-mail Address

About Your Company

Number of years in this business:

Tax Status:

Individual Partnership S-Corporation
Corporation L.L.C.

Please give an overview of your business operations.
Be as specific as possible.

Total number of employees:

Number of F/T Employees	Number of P/T Employees

Number of principals / owners: Exclude owners? Yes No

Payroll

Total Gross Receipts $:

Payroll of owners $:

Employee Payroll $:

Insurance History - Provide three year history if applicable

Company	Year	Claims	Amount Paid	Annual Premium



When would you like your policy to take effect?
ASAP Within one month In one to two months More than two months When my current policy expires

If you currently have Workers' Compensation, please indicate the following:

Current provider:

Current Policy Expiration Date:

mm/dd/yy

Please answer all. If the answer to any of the following is yes, please give details in the comments box at the bottom of this section.

Yes No

Any work performed underground or above 15 feet?

Yes No

Is applicant engaged in any other type of business?

Yes No

Are sub-contractors used?

Yes No

Any prior coverage declined/cancelled/non-renewed (last 3 years) ?

Please give details on all Yes answers above and provide any additional information
that would help to provide your company accurate quote.