Workers Compensation Application – Orr & Associates Insurance Services

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7am - 5pm PST | Monday - Friday

Workers Compensation Application

"*" indicates required fields

1Who will be insured?

2Location

3Business Details

Hidden

Industry

Hidden

Class Code

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Agent ID

First and Last Name*

Business Name (if applicable)

Email*

Phone*

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*

Number of Employees

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?*

Approximate date is OK.

Month

Day

Year

How many years have you maintainted continuous coverage without a lapse?*

1

2

3+

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National Producer Number 8395753