Workers’ Compensation Insurance

Name*

Address*

Street Address City State ZIP Code

Phone

Email

Proposed Effective Date:*

Current Carrier*

Part 1

Workers’ Compensation Insurance (Coverage A and C)

Statutory Coverage as provided by the following states: California

Coverage includes Medical, Rehabilitation and Loss of Income Benefits for injuries arising out of a work related injury.

Part 2

Employers Liability Insurance (Coverage B)

Limits of Insurance
Bodily Injury By Accident – $1,000,000 Each Accident
Bodily Injury By Disease – $1,000,000 Policy Limit
Bodily Injury By Disease – $1,000,000 Each Employee

Rating Information

Class Code

Apt/Condo Complex Operation

9011 – Estimated Annual Payroll

Apt/Condo Complex Operation

8810 – Estimated Annual Payroll

Clerical Only

8740 – Estimated Annual Payroll

Apt/Condo Complex Operation

9015 – Estimated Annual Payroll

Building Operations

8742 – Estimated Annual Payroll

Outside Sales

*10% safety discount for all CAA Members plus other applicable CAA discounts available

Experience Modification Rate?

How many locations:*

(you may provide a list)

Would you like to provide a list of locations?*

Yes
No

Locations*

Phone*

Fax

Email

Federal I.D. #*

# of Years in Business*

Please choose one:*

Corporation
Limited Liability Company
Sole Proprietor
Partnership

Loss Information

No losses in past 5 years*

Yes, I do not have any losses in the past 5 years
No, I do have losses in the past five years

**Forward 5 years currently dated loss runs with application

File Upload*

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.

Please upload all documents related to the losses for the last five years.

Officers/Partners

Name	% of Ownership	Included/Excluded (Yes or No)

Beginning the tenancy

During the tenancy

Ending the tenancy

Part 1

Part 2

Rating Information

Loss Information