6400 Laurel Canyon Blvd. Suite 305
North Hollywood, CA 91606
Phone. 818.789.0722
Fax. 818.789.2835
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CEO/ President Name
Mailing Address
Mailing Address 2
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Company FEIN or President SS#
Year Business Was Established
Email Address
Contact Phone Number
Current information
Class Code
Description of Duties
Full-time / Part-time
Employees
Payroll
/
/
/
/
/
Owners/Officers Name
Ownership %
Title
Coverage Desired?
Yes
No
Yes
No
Yes
No
Workers comp history
Ownership Industry Experience
WC Experience
None
1 Year
2 Years
3 Years
4 Years
4+ Years
Current Carrier
Effective Date
Anniversary Date
Payroll
Premium
Current Year
Current Year
1'st Prior Year
1'st Prior Year
2'nd Prior Year
2'nd Prior Year
3'rd Prior Year
3'rd Prior Year
Prior 3 Years Loss Runs
(if available)
Description of Operations/
Additional Notes
(Locations, loss history, etc.)
1'st Year
2'nd Year
3'rd Year
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