J&C Corbett Insurance Services, Inc.

Workers' Compensation

Please answer all the questions below and press submit to receive a free quote.

Business Name:*

Years in Business:*

Physical Address: (No PO Box)

Mailing Address: (if different)

Phone:*

Cell Phone:*

Fax:

Email:*

Social Security or Tax ID #:*

Employer Development Dept. (EDD) #:

Company Type:*

Bankruptcy in the Last 7 Years:*

Sole Owner

Partnership

Corp.

Yes

Names of Owners, Officers, or Directors:

License #:*

Classification(s):*

Num. of Full-Time Employees:*

Num. of Part-Time Employees:*

Are you already a client?

Corbett Code or Bond Number:

Please provide information on the hourly wages paid for each class of employee.

Hourly Wage	Type of Work Performed
Example: Up to $25/hour	Carpentry

Please provide information on the annual payroll for each class of employee.

Annual Payroll	Type of Work Performed
Example: $80,000	Carpentry

Any work-related injuries or claims in the last 5 Years?*

How soon is insurance needed?*

Yes

Name of current or previous workers' compensation carrier:

NOTE: You must include copies of any LOSS REPORTS received from your Carrier for the previous 3 years. Please fax or e-mail these reports to our office.)

See our privacy policy.

Questions? Call us!
1-800-400-1125

Our locations:

Main Office:
609 Court Street
Woodland, CA 95695

Builders Exchange Office:
1331 T Street, Suite 10
Sacramento, CA 95811

Hours of operation:
8 am - 4:30 pm Monday - Friday

Phone: 1-800-400-1125
Local: 530-419-2000
Fax: 530-419-2019
Email:
info@corbett-insurance.com

California License Number: 0D34028