Workers Comp!
WE SAVE YOU MONEY.

California Businesses:

Let us show you how we save our California clients HUNDRED$, even THOUSAND$ of Dollars on their Workers Comp Insurance Policies!



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CA-WorkersCompensation.com
Imperial Insurance
22938 Lyons Avenue
Newhall, CA 91321
PHONE: (800) 645-8884
FAX:(661) 290-2770

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CA Ins. Lic. #0B04327



For Other Personal and Business Insurance Programs, Visit us at: ImperialInsuranceAgency.com

On-Line Workers Comp Insurance Quote Form

One Simple Form - takes only 2-3 Minutes!
Call Now to talk to a Live Agent or complete the form below!
Your Name:
Your Company's Name:
Street Address:
City:
State (Must be California):
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
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.)
FEIN or Social Security #:
(now required by all comp carriers to quote)
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
 
Contractor State Lic No., if applicable:
 
Thank you for filling out this form 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.
 
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