Workers Compensation Request Form

Contact Information

Please provide us with the following information. Fields marked with * are required fields.

*First Name:
*Last Name:
*Title:
*Phone:
*E-mail

Business Information

*Business Name:
*Entity type:
*Federal ID Number (FEIN):
*Address:
*City:
*State:
*Zip Code:
Web site address:
Best time to contact:

Additional Information

Do you operate out of more than one location?

Yes No

What are your gross annual sales?

How many employees?

full time part time

What is your total annual payroll?

Do you currently have workers compensation insurance in place?

Yes No

Have you had any claims in the last five (5) years?

Yes No

If yes, please provide a description.

Please provide a 3-4 sentence description of your business operations, products sold, and or services provided.

Testimonials

I´m amazed, you guys gave me better coverage and for less money than I was paying, you guys are great!

Anne C.
Pasadena, CA
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Binney, Chase & Van Horne has provided our company with continuous high quality service and value for our insurance needs for three generations.

D.E. Benjamin,
Benjamin Electric Company
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> Read More Testimonials

Binney, Chase & Van Horne, Inc.
600 S. Lake Ave. Suite 306 Pasadena, CA 91106
(626) 792-7654 - Outside of the 626 area, phone our toll-free number: 800-585-8787

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