CWIRM - QUOTE APPLICATION
The Easiest, Simplest, Shortest Workers' Compensation Quote Form. Ever.

If you have any questions, just call (800) 760-6204.

Highlighted = Required

CONTACT INFORMATION
Name
  
Phone
  
Fax
  
Email
  

CORPORATE INFORMATION
Doing Business As (DBA)
  
Corporate Name
  
Address
  
City
  
State
  
Zip
  
Years In Business
  
Federal Tax Id (FEIN)
 
Business Type
 
Proposed Effective Date
 
Number of Owners
  
Number of Locations
  

CURRENT SAFETY PROGRAM
Do you have a written safety program?
   Yes No
Do you have a return to work program?
  Yes No
What is the frequency of your safety meetings?  

OWNERS/OFFICERS
Percentage must total 100.
Name
Title
Ownership %
Exclude?

Click Here for a Description of Each Class Code Below OR Click Here for a Summary of All Class Codes
LOCATION 1 - Address Same As Corp?
Class Code
# of Employees
Estimated Annual Payroll
Name
    
Address
    
City
    
State
    
Zip
    

PRIOR CARRIER INFORMATION (optional, but try to give at least current carrier name)
Year
  
 
Carrier Name
 
 
Policy Number
 
Year
  
 
Carrier Name
 
 
Policy Number
 
Year
  
 
Carrier Name
 
 
Policy Number
 

DESCRIPTION OF BUSINESS
(optional, but helpful if you are not sure of your "class codes")

ANY EXTRA REMARKS (optional)

DO YOU BELONG TO ANY ASSOCIATIONS?
(optional, but we give discounts to certain associate members)

HOW DID YOU HEAR ABOUT CARE WEST? (optional)