Workers' Compensation Supplement

Use when completing a Business Package application.

Call 650-858-1123 for assistance

Include or Exclude Coverage for Owners & Officers *
You may choose to cover all owners/officers for injury, or exclude them from coverage.
Only required if Owners/Officers included.
Provide Legal Names, Dates of Birth, Titles, and Duties of all Owners/Officers.
Is Group Health Insurance provided to your employees? *
List any additional information.

We will email you with any remaining questions.

Email additional comments to  Please include your business name for reference.