Application – Workers Compensation – Orr and Associates

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800-858-1315

7am - 5pm PST
Monday - Friday

Workers Compensation

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Controllling Agent
Briefly describe your business operations.*
E.g., I sell and deliver flowers.
Name*
First Last
Email*
Phone*
Business Name (if applicable)
Entity Type*
Number of Employees
Year Business Started*
Annual Employee Payroll (Estimated)*
Do you hire subcontractors?*
- Yes
- No

Location
Address*
Street Address City State / Province / Region ZIP / Postal Code

Coverage
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+
In addition to Workers Compensation, please indicate any other quotes to include.
- Commercial Auto
- General Liability
- Professional Liability
- Property
- Umbrella

800-858-1315

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Mon - Fri, 7am - 5pm Pacific

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