Premier Class Insurance Services, Inc.
First Tower Insurance

 

For a prompt, free quote, please complete our online application form.
If you would like to have our agent contact you directly for this information,
please include your name and phone number in lieu of completing this form.

WORKERS COMPENSATION INSURANCE ONLINE QUOTATION FORM

First name:
Last name:
Position:
Organization:
Nature of your business:
Street address:
City:
State/Province:
Zip/Postal code:
Country:
Work Phone:
Years in business:
Accounting Records Contact Person:
Accounting Records Contact Phone Number:
FAX:
E-mail: (required to process)
Proposed Effective Date:
Proposed Expiration Date:

Describe Operation:
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List all other entities the insured owns or is a part owner:
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Does the insured have employees for the other entities?: Yes no

List the carrier of coverage:

Policy Start Date (Year):

Policy End Date (Year):

Does the insured's operation include any delivery or driving exposure? Yes no

What are the hours business is open to the public?
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What are the hours worked by employees?
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Will the owner be active on site? Yes no

Describe hiring and training practices:
Please check all that apply.
Applications and References are checked
Safety and Incentive Program
MVRs
Drug Testing
Pre-employment Physicals
Back X-ray
SB 198
Safety Committee
Safety Program with meetings?
Accident Investigations

Are employees being paid by piece work or hourly wage? Hourly Wage Piece Work

Describe employee training.
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Safety meetings are held:
Please check all that apply.
Weekly Bimonthly Monthly Quarterly Semiannual

Total number of employees:
Approximate Annual Payroll: $
Approximate Annual Gross Earnings: $

Does employer provide modified work for injured workers? Yes no
Does employer provide employee medical coverage? Yes no

If new venture, explain owner's prior business experience for the last 3 years.
Include the name of the business, the owner's duties, location and time employed.
Type into the text box below.

If new venture or new purchase, what date did Insured hire employees?

Has coverage been canceled in the last 3 years? Yes no

If so, list all cancellations and reasons for cancellations.
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Other Information and Comments
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PREMIER CLASS INSURANCE SERVICES, INC.
P.O. Box 7325
Orange, CA 92863-7325

PHONE:   (714) 453-0611
TOLL FREE:   (866) 441-0321
FAX:   (714) 453-0615
E-mail:   info@firsttower.com

CA Lic. #: 0D08422

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We are a premier supplier of cargo insurance, marine insurance, aviation insurance, protection and indemnity insurance, P and I, carriage by sea insurance, carriage of goods by road, goods by rail insurance, road haulage insurance, bill of lading, voyage charter, time charter insurance, freight forwarder, carrier, merchant, terminal operator, vessel insurance, aircraft insurance, airplane, airport, contract of insurance, certificate of insurance and world wide representatives.