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Workers' Compensation

Please fill out the information below. Fields marked with * are mandatory.

Contact Information
   
* First Name:
* Last Name:
* Position:
* Phone:
* Email:
   
Name of School:
Address:
City:
State:
Zip:
Additional Location(s):
 

Coverage Information
 
Is school a current member of the
California Association of
Independent Schools?
Yes No
   
Federal ID Number:
Current Workers’ Compensation carrier:
Current Workers’ Compensation
policy expiration date:
   
Number of Full-Time Employees:
Number of Part-Time Employees:
   
Group Health Coverage?
Yes No
If Yes, please provide the
name of the health carrier:
   
School sponsored extracurricular activities
(on and off campus)?
Yes No
If Yes, please describe:
   
Volunteers?
Yes No
If Yes, please describe duties:
   
Active Safety Program?
Yes No
Four years loss history:
If you have a PDF or Word Document describing your loss history, please attach it using the buttons on the right.
 
   
Compliance with SB 198?
Yes No
   
Safety Incentive Program?
Yes No
 

Estimated Annual Payroll by Classification
   
8810 – Clerical:
8868 – Teachers:
9101 – Maintenance:
 
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Please click on the "Submit Application" button below.
 
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