Ghost Workers Comp - Republix Risk Mitigation Insurance Solutions

Workers Comp Ghost Policy Form

This questionnaire is designed to generate a workers compensation quote for those contractor who do not have employees but are required by the CSLB or a "client's contract" to carry a workers comp policy. These policies are being called "ghost" policies because the owner of the policy does not have any employees.

Please answer all the questions below so we can generate a workers compensation proposal for your risk.

"*" indicates required fields

Business Details

Name of Person Completing Form:*

First Last

Phone Number:*

Email:*

Business Name:*

Business Entity:*

FEIN / Tax-ID Number:*

Mailing Address:*

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?*

Yes

Physical Address:*

Street Address City State ZIP Code

Company Website:

Effective Date

Contractors License #*

Brief Description of Operations:*

Year Business Started:

Number of Employees:

Estimated Annual Employee Payroll:

Estimated Annual Revenue:

Owners*

Name

% Ownership

Additional Contractor Details

Contractors License #*

% of work Subcontracted out

% of Residential Work

% of Commercial Work

% of Remodel/Install work

% of New Construction Work

% of Service/Maintenance Work

Do you perform Government/Municipality Work?