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Call Us 559-320-2247 Agency License #0F00726

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Name of Company

Address

Phone Number

Description of Operations (25 words or less)

FEIN or SS#

Name of Owners or Officers (Up to 4)

Contact Name & Number

Email Address

Class codes or types of work performed by employees and annual payroll for each

Type 1

Payroll

Number of Employees

Type 2

Payroll

Number of Employees

Type 3

Payroll

Number of Employees

Type 4

Payroll

Number of Employees

Type 5

Payroll

Number of Employees

Years of Workers Comp History

Annual Expiration Date

Valid Accurate quotes can only be provided with "paper" loss reports from your current and past workers comp companies, but we can give you a general idea of the cost

If you are a contractor, fill out your license number below. We can provide you with your past workers comp history and a letter or phone number to make it easier to request your loss history

Contractor License Number

If you have any questions reach out to Mark Rivard now!

Email at: mrivard@ccisinsurance.com
Call at: 559-320-2247