Safepro Insurance Services

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Workers Compensation Quote
Company Name:
Owners Name
Contractor License Type:
Contractor License Number(s)
Years of Experience:
Years in Business
Type of Business:
Number of active Current Owners/Partners/Officers
Street Address:
State, Zip:
Please describe your operations in detail:
Gross Receipts Including Labor & Material & Cost of Sub:
Cost of Sub Including Labor & Material:
Payroll Excluding Owners & Officers but Including Leased Labor:
Number of full time employees:
Number of part time employees:
Will you use subcontractors?
Yes No
If yes, list trades of subcontractors used:
Average value of projects:
Maximum number of jobs running at same time:
Are you currently insured?
Yes No
If no, please state reason for applying:
If yes, who is your current carrier?
Policy expiration date:
How many years have you been continuously insured?
Any claims in last 5 years?
Indicate percentage of work performed
(Total should equal 100%):

% Remodeling
% Non-structural remodel
% Repair and Service
% Tenant Improvement
% New Construction
% Other


(Total should equal 100%):

% Commercial
% Industrial
% Single Homes
% Apartments
% Condominiums
% Town-homes
% Tract-homes & PUD’s
% Govt. & Public
% Other


In What Capacity Do You Operate?
(Total should equal 100%):

% General Contractor
% Subcontractor
% Owner/Builder
% Developer
% Spec Builder
% Construction Management
% Other


Where Do You Operate?
(Total should equal 100%):

% California Operations
% Outside California


Annual Payroll by classification,
for example, painting, plumbing,
framing, office, etc.
If owners and officers to be included
Please specify the annual salary:
Tell us more about your Business:

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