Skip to content
Back
(951) 331-0350
Workers Compensation APplication
"
*
" indicates required fields
1
Who will be insured?
2
Location
3
Business Details
This field is hidden when viewing the form
Agent
This field is hidden when viewing the form
Agent Phone
This field is hidden when viewing the form
Agent Email
This field is hidden when viewing the form
Industry
This field is hidden when viewing the form
Class Code
Your Name
First
Last
Business Name (if applicable)
Email
*
Phone
*
Email Consent
By entering my email and clicking “Get My Quote,” I agree to receive recurring marketing emails from Orr & Associates Insurance Services. Consent is not a condition of purchase; I may opt out at any time. For more information, please visit our
Privacy Policy
. If you have questions or to opt-out, please call us at 800-311-3081.
Phone Call Consent
By entering my phone number and clicking “Get My Quote,” I agree to receive recurring marketing and informational calls from Orr & Associates Insurance Services, even if my number is on a Do Not Call list. Consent is not a condition of purchase; I may opt out at any time. For more information, please visit our
Privacy Policy
and
SMS Terms & Conditions
. If you have questions or to opt-out, please call us at 800-311-3081.
SMS Text Consent
By checking this box, I consent to receive (Conversational) SMS messages from(Orr & Associates) You can reply "STOP" at any time to opt-out. Message and data rates may apply. Message frequency may vary, text HELP for assistance. For more information, please visit our
Privacy Policy
and
SMS Terms & Conditions
. If you have questions or to opt-out, please call us at 800-311-3081.
Location Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Mailing Address
*
Same as previous
Street Address
City
State / Province / Region
ZIP / Postal Code
Briefly describe your business operations.
*
E.g., I sell and deliver flowers.
Entity Type
*
- Select -
Individual
Partnership
Corporation
LLC
Other
Number of Employees
- Select # of Employees -
0
1
2-5
6-10
11-25
26+
Year Business Started
*
Annual Employee Payroll (Estimated)
*
Do you hire subcontractors?
*
Yes
No
Are you currently insured for workers compensation?
*
Yes
No
Have you carried any workers compensation policies in the past 5 years?
*
Yes
No
When does your current policy expire?
*
MM slash DD slash YYYY
How many years have you maintainted continuous coverage without a lapse?
*
1
2
3+
