Contractor Workers Compensation – Capital Partners Insurance Agency, Inc

Capital Partners Insurance Agency, Inc

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(800) 889-7162

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Call Us Toll Free

(800) 889-7162

Home
About Us
Products
Applications
Contact

Contractor Workers Compensation

Thank you for allowing Capital Partners Insurance Agency, Inc. the opportunity
to save you money on your insurance. Please fill out the information
below and click the "submit" button.
Business Name:
Year Established:
Contractor License #:
Name:

First NameLast Name
Phone Number:

Area CodePhone Number
E-mail:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business FEIN/Tax ID:
Description of Business:
Number of Full-Time Employees
Number of Part-Time Employees:
Number of Total Employees:
Business Entity:

IndividualLLCCorporationPartnershipAssociationJoint VentureOther
Number of Locations:
Franchise:

YesNo
Are employee health plans provided?:

YesNo
Current Insurance Company:
Driving Radius:

No Driving< 50 miles51-100 miles101-250 miles251-300 miles> 300 miles
Type of Vehicles:

SUV'sTrucksVansSedansTractorsOther
Number of Vehicles Used:
Number of Drivers Used:
Class Code/# of Full Time Employees/# of Part Time Employees/Annual Payroll:
Officer Names/Title/% of Ownership/Included on Policy:
Explain all Exterior and/or Interior work performed:
Types of machinery and hand tools used:
Percentage of Residential Business:
Percentage of Commercial Business:
Any work performed above 2 stories?

YesNo
If yes, explain:
Any use of Cranes?

YesNo
Any use of Scaffolds?

YesNo
Any Concrete tilt-up work?

YesNo
Any Roof Exposure?

YesNo
Material Handling Exposure?

YesNo
Manual Lifting?

Below 50 lbsAbove 50 lbs
Work Performed Underground or Aboveground more than 15 Feet?

YesNo
Should be Empty:

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Capital Partners Insurance Agency, Inc / CA Ins License #:6012780

369 S Doheny Dr. Suite 207 Beverly Hills, CA 90211

Phone: (800) 889-7162 Fax: (888) 248-7333

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