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Workers Compensation Insurance Application

Company Name*
Years in Business
Applicants Name*
Street Address*
Suite #
County*
City*
State*
Zip*
Mailing Address
Suite #
County
City
State
Zip
Phone*
Mobile Phone
Work Phone
Fax
Email*
Website
Nature and Description of Business
Type of Business Entity:
Current Policy Expiration:

Premise Locations:
Location # 1
Street Address
Suite #
County
City
State
Zip
Within City Limits ?
Owner
Tenant
Year Built
# of Employees
Annual Revenues
% Occupied
Natured and Description of Use
Class Codes
Catergories, Duties, Classification
Workers Comp Rate
Estimated Premium

Location # 2
Street Address
Suite #
County
City
State
Zip
Within City Limits ?
Owner
Tenant
Year Built
# of Employees
Annual Revenues
% Occupied
Natured and Description of Use
Class Codes
Catergories, Duties, Classification
Workers Comp Rate
Estimated Premium

Location # 3
Street Address
Suite #
County
City
State
Zip
Within City Limits ?
Owner
Tenant
Year Built
# of Employees
Annual Revenues
% Occupied
Natured and Description of Use
Class Codes
Catergories, Duties, Classification
Workers Comp Rate
Estimated Premium

Location # 4
Street Address
Suite #
County
City
State
Zip
Within City Limits ?
Owner
Tenant
Year Built
# of Employees
Annual Revenues
% Occupied
Natured and Description of Use
Class Codes
Catergories, Duties, Classification
Workers Comp Rate
Estimated Premium

Location # 5
Street Address
Suite #
County
City
State
Zip
Within City Limits ?
Owner
Tenant
Year Built
# of Employees
Annual Revenues
% Occupied
Natured and Description of Use
Class Codes
Catergories, Duties, Classification
Workers Comp Rate
Estimated Premium

Current Carrier Information
Carrier Name
Policy #
Effective Date
Expiration Date
Policy Limit Each Accident
Disease Policy Limit
Disease Each Employee Limit
Dedcutable Medical
Deductable Indemnity
Total Premium
Current Experience Mod
Current Deductable

Loss History
Date of Claim
Amount Paid
Amount Reserved
Claim Status

Loss History
Date of Claim
Amount Paid
Amount Reserved
Claim Status

Loss History
Date of Claim
Amount Paid
Amount Reserved
Claim Status

Loss History
Date of Claim
Amount Paid
Amount Reserved
Claim Status

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 TO THE ABOVE STATEMENT, PLEASE PROCESS MY QUOTE.

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Allegheny Pacific Insurance Services, Inc.
State of California Department of Insurance License # 0F82733
Corporate Office: 18405 Park Point Ct., Hidden Valley Lake, CA 95467
Office hours: Mon – Fri from 9 am to 5 pm. Call Us 877-ALLPAC1 Fax Us 707-929-0047
Please be aware that coverage cannot be bound, canceled or altered by sending a message via this Web site.
Contact your local Allegheny Pacific Insurance Services office for assistance with changes to your policy.
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