Workers Comp Quote | Jaikar Insurance Services

1 Business Info & Type of Work?

Business Name Business Address, City, ZIP Exact Type of Work / Business

Number of Employees (incl. owner if on payroll) Total Annual Payroll $

Paid W2 or Cash?

W2 Cash

List what each employee does (e.g., 1 clerk, 2 cooks, 1 driver)

Do you use Subs / 1099?

Yes No

Are they insured with WC?

Yes No

Annual Cost of Subs $

Number of Owners / Officers

Exclude Owners?

Yes No

Allowed in CA with form

FEIN # CA Contractors License # (if applicable)

Any work outside CA?

Yes No

Any remote / work-from-home employees?

Yes No

Current WC Company & Premium $

Any Injury Claims Last 4 Years?

Yes No

Explain X-Mod / Experience Mod (if known)

Safety Program / Training / Return-to-Work?

Yes No

Effective Date Needed

Need COI Today?

Yes No

Name (Required) Phone (Required)

Email (Required)