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Business Information

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Business Name *

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FEIN or TAX ID Number? *

How Long In Business? (Years) *

Business Description / What do you do? *

Business Address *

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Number of Employees *

How many Part time? *

How many full time? *

Please describe how many employees do what type of Job *

Class Description

Job 1 *

How many employees (J1) *

Total Salary for this job (J1) *

Job 2 *

How many employees (J2) *

Total Salary for this job (J2) *

Job 3 *

How many employees (J3) *

Total Salary for this job (J3) *

Does the owner want to be excluded or Included? *

How many years have you had Workers Comp? *

Have you had any claims? *

If yes Please explian in Comments Section Below below! *

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Califonia Lic # 0801925 | NPN # 2543434

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Champ Insurance Services
California license # 0801925
National Producer # 2543434
92 Corporate Park C 777
Irvine CA, 92606
949-535-1099
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