Workers Compensation Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information

First Name *

Last Name *

E-Mail Address *

Primary Phone Number *

Alternate Phone Number

Company Information

Street *

City *

State *

ZIP / Postal Code *

Multiple Locations *

Company Name *

Company Owner *

Additional Information

Business Type *

Do you currently have insurance? *

Current Insurance Provider

Expiration Date

Nature of Business

Year Business Established

Annual Employee Payroll *

Number of Part-Time Employees

Number of Full-Time Employees

FEIN/Tax ID or SSN (if a Sole Proprietor) *

Officers including their Titles & Percentage of Ownership (must equal 100%) *

How did you hear about us?

Notes/Additional Information

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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Location

2295 Fletcher Pkwy
Suite 100
El Cajon, CA 92020
Phone: 619-797-1440
Email: info@kennedyinsurance.com