California Healthcare Group Workers Compensation - Redefining Workers Compensation for the Nursing Home Industry

Business Name:

Does My
Company qualify
for Group
Workers Compensation?

Contact Person: *

Federal Tax I.D.#:

Address:

City:

State:

Zipcode:

Phone: *

Fax:

E-Mail: *

How did you hear about us?

Years in Business:

Experience Modification:

Description of Operations?

	Clerical Payroll	Non Clerical Payroll	Workers Compensation Premium
2000-2001	$	$	$
2001-2002	$	$	$
2002-2003	$	$	$
2003-2004	$	$	$
2004-2005	$	$	$
Estimated 2005--2006	$	$	$

Do you have prior coverage? YES NO

Additional Information: