Questions?
Ask the Agent! Use the form below
or give us a call.
Phone: (800) 750-8888
Fax: (866) 353-3083
Workers Compensation Quote
One Simple Form - takes only 2-3 Minutes!
YOUR PERSONAL | COMPANY DATA:
Your Name:
Your Company's Name:
Street Address:
City:
State: (Must be California)
Zip/Postal:
E-Mail: (Required)
E-Mail again: (for accuracy)
Phone:
Fax: (Optional)
Your Company Website:
Currently Insured?
(If yes, list carrier, and # of years continuous. If none, type
NONE)
List Claims & Amounts Paid
(If none, type NONE)
Years In Business:
Business type:
(proprietorship, corporation, etc.)
UNDERWRITING INFORMATION:
Describe IN DETAIL, Your Business Operations:
Payroll Class #1:
List Class Code # if you know it, and describe payroll class:
Insert Annual Payroll in dollars for this class here:
$
Payroll Class #2: (if none, leave blank)
List Class Code # if you know it, and describe payroll class:
Insert Annual Payroll in dollars for this class here:
$
Payroll Class #3: (if none, leave blank)
List Class Code # if you know it, and describe payroll class:
Insert Annual Payroll in dollars for this class here:
$
Send my quotation via:
E-Mail Fax Regular Mail
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COMPLETELY!
We value your input as PRIVATE information. Every step has been
taken to insure your privacy, security, and our intent is to release quote information only
to you. We will not give your data to ANY other person or group for sales, marketing,
or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to
release us from any liability should this information be accidentally viewed by others.
Our intention is to maintain your complete privacy.
Yes, I Agree.
Please Send Me a Workers Compensation Quote NOW!
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HAD / Professional Insurance Associates, Inc | Mailing Address: P.O. Box 8480, Porter Ranch, CA 91327
1100 Industrial Road, Suite 3, San Carlos, CA 94070 | 6320 Canoga Avenue, Suite 1500, Woodland Hills, CA 91367
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