# 方圓保險與理財

## Alina Insurance & Financial Services

#### 8780 Valley Blvd, #R, Rosemead, Ca 91770

### Tel: 626-757-2765 Fax: 888-473-0186 Email:alinachen8@yahoo.com

### Worker’s Compensation Insurance Questionnaire

Name Insured: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Mailing Address:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone#: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Fax: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ FEIN(Tax ID #)(9 Digit):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Desired Effective Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Year Started\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Physical Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Business Operations\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Officer/Owner: Name/DoB\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_INC/EXC\_\_\_\_\_\_\_\_\_\_ Name/DoB\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_INC/EXC\_\_\_\_\_\_\_\_\_\_ Payroll Information: WC Code\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ # Of Employees F/T\_\_\_\_\_P/T\_\_\_\_\_\_\_Total Payroll\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ WC Code\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ # Of Employees F/T\_\_\_\_\_P/T\_\_\_\_\_\_\_ Total Payroll\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ WC Code\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ # Of Employees F/T\_\_\_\_\_P/T\_\_\_\_\_\_\_ Total Payroll\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Any Delivery? Y/N \_\_\_\_\_\_\_\_\_Travel Out Of State? Y/N\_\_\_\_\_\_\_\_\_\_\_24Hours? Y/N\_\_\_\_\_\_\_\_\_\_\_\_ If Any Yes To Above, Please Explain\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Prior Insurance? Current Premium:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Company\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Year\_\_\_\_\_\_\_\_\_\_\_\_\_\_Pol#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Company\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Year\_\_\_\_\_\_\_\_\_\_\_\_\_\_Pol#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Company\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Year\_\_\_\_\_\_\_\_\_\_\_\_\_\_Pol#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Any Losses? If so, please describe \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_