Workers Compensation Quote Application
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Commercial Carriers Insurance Agency, Inc.

Truck Insurance Quote - Workers Comp

DIRECTIONS: To receive a quote for your current Workers Compensation insurance needs,
simply complete the application and push "SUBMIT" - one of our Account Executives will contact you shortly. If for any reason you feel uncomfortable using our online application, contact us
toll-free at (800) 229-8782 or local line (562) 404-4900. Marcy Brinkman, Sales Manager.

We currently offer coverage to operations based in the following states:

Email (Double check before submitting)
Please list any special notes you would like us to know about, such as issues with your current protection/service or special business operations.
How did you hear about us?

Web address from a:
Letter Mailer Friend Magazine
MSN Google Yahoo

Company Name

Owner's Name

Your Name (If other than owner) Same as owner

Phone Number:


Business type

Provide a brief description of your operation:


What is your estimated ANNUAL payroll

State(s) Classifications Estimated Annual Payroll


Any employees live outside of California?

Yes No

Any employees travel outside of California? If so where and how often

Yes No

Do you hire any family members?

Yes No

Have you carried
Workers Compensation before?

Yes No prior coverage

Will drivers perform any manual
loading or unloading?

Yes No

Do you have a formal Safety Program?

Yes No

Quote subject to change based upon verification of supplied information.

Commercial Carriers Insurance Agency, Inc., License No. 0567750
A Subsidiary Of the Meadowbrook Insurance GroupSM


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