California insurance from Wise Insurance Agency
FAST & FREE Online Califonia Business and Personal Insurance Quotes!
Personal Auto, Homeowners Insurance from Wise Insurance Agency
Personal Auto, Homeowners Insurance from Wise Insurance Agency
 • Auto Insurance

 • Homeowners \Renters

 • Personal Umbrella

 • Recreational Vehicle

Commercial and Business Insurance from Wise Insurance Agency
 • Contractor Liability

 • Business Owners

 • Innkeepers Insurance

 • Workers Compensation

 • Builder's Risks

 • Commercial Auto

 • Special Event


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California Insurance Lic #0770590
 
On-Line Workers
Compensation Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal / Company Data:

Your Name:
Your Company's Name:
Street Address:
City:
State: MUST be California!
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again (for accuracy):
Phone:
Fax (optional):
 

Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
 
List Claims & Amounts Paid
(If none, type NONE)
 
Years In Business:
 
Business type:
(proprietorship, corporation, etc.)
 

 
Underwriting Information:
 
Describe IN DETAIL,
Your Business Operations:
 
Payroll Class #1:
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here: 		$
 
Payroll Class #2: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here: 		$
 
Payroll Class #3: (if none, leave blank)
List Class Code # if you know it, and describe payroll class: Insert Annual Payroll in dollars for this
class here: 		$
 
 
Send my quotation via: E-Mail Fax
Regular Mail

 
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We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Wise Insurance Agency . 2 California Avenue. San Rafael, CA 94901 . Lic#0770590
Toll Free Phone: 800-939-8730 . Phone: 415-258-9912 . Fax: 415-457-6428
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