The following is a guideline to the information that the Insurer will request in order to provide a proper quote.

1. Last five (5) years loss runs with Detail (medical, indemnity, reserves broken out), Premium for each year Currently Valued.

2. Current year loss runs dated within 30 days.

If you have no losses to date, please make the statement, “We have no Losses in the current policy year.” on your Company Letterhead.

We can provide a letter to fax if you do not have your Currently Valued Losses.

3. Payroll by Class Code for each of the last 5 years and estimate for current year.

Class Code / Payroll Class Code / Payroll Class Code / Payroll

2005

2004

2003

2002

2001

2000

Workers Compensation Premium

2005

2004

2003

2002

2001

2000

4. Short Description of all loss time claims. (Listed on OSHA 200, 300 or 300a Log under Time Away From Work) I will discuss each loss time claim individually with you.

5. Your last Monthly Workers Compensation Payroll Report..

6. Your last Workers’ Compensation Insurance Rating Form (provided each year by the CA WCIRB to determine your next years experience modifier)

7. A company Brochure, if you have one, or a letter about Your Company, past, present and future. (You usually provide one for your Auto Carrier and Liability packages.)

8. CA EDD form DE-2088 which reports the turnover rate.

9. Federal ID Number (FEIN) and State ID Number