Workers’ Compensation Insurance

"*" indicates required fields

Name*

Address*

Street Address City State ZIP Code

Phone

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

Locations*

Phone*

Fax

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)

Phone

This field is for validation purposes and should be left unchanged.

Part 1

Part 2

Rating Information

Loss Information

Featured Webinars

Latest News

Updated notices now available following court ruling

Raising the rent can raise legal risks, especially in California

Bill to extend eviction notices revived for another possible vote in Assembly committee

Part 1

Part 2

Rating Information

Loss Information

Featured Webinars

Landlord’s Guide to California’s Rent Increase Laws

Understanding the Section 8 Housing Voucher Program

Tenant Screening Process Webinar

Latest News

Updated notices now available following court ruling

Raising the rent can raise legal risks, especially in California

Bill to extend eviction notices revived for another possible vote in Assembly committee