EMPLOYERS Work Comp Quote Request

Please contact Patrick Kim at 925-296-5478 (pkim@beerepurves.com) if you have any questions related to Workers' Compensation or the form below.

 

    • Example 1 Joe Smith dba Smith's Autobody
    • Example 2 ABC Corporation dba Al's Bottling Company
    • The company's legal name can be located on tax documentation
  1. Yes No
    • A company's TIN may be found in tax documents. An example is 89-555555.
    • Do not enter the dash.
    • Example 1: Insurance brokerage
    • Example 2: Restaurant
    • Example 3: Law Office
    • Example 4: Macaroni Manufacturing, etc.
  2. Some Workers' Compensation carriers include:

    • Ace
    • Chartis
    • Everest National
    • Farmers
    • FirstComp
    • Hartford
    • Republic Indemnity
    • State Farm
    • State Fund
    • Travelers
    • Zurich
    Not applicable
  3. No claims have been incurred in the last four years.
    Yes. Please note that claims history (aka loss runs) will be required to substantiate the claims.
  4. Example 1

    • Class Code: 8810
    • Job Description/Title: Administrative Assistant or Clerical
    • # of EEs: 7
    • Annual Estimated Payroll: $3,500,000.00

    Example 2

    • Class Code: 8742
    • Job Description/Title: Sales Representative
    • # of EEs: 12
    • Annual Estimated Payroll: $12,000,000.00

    NOTE: Groups with a Workers' Compensation policy may find their covered class codes on the policy Declarations page.
    Class Code Job Title/Description # of EE's Estimated Annual Payroll
    • If the group currently offers an Anthem Blue Cross Small Group Medical plan, they may be eligible for discounts on the Workers' Compensation premium and possibly the Medical premium.
    • If the group does not currently offer Anthem Medical but is looking to do so, select “pending.”
    Pending Not applicable

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