Contractor Workers' Comp Application

Business & License

Enter your CSLB number first — we'll pull what we can from the state license record.

CSLB license # *

Years in business

Business name *

Contact first name *

Contact last name *

Phone *

Email *

Entity type *

FEIN *

Physical address *

Mailing address is the same as the physical address

Officers & Owners

List every officer, owner, partner or LLC member, along with the percentage each one owns — the percentages must add up to exactly 100%. For each person, choose a Status: Included to cover them under the workers' comp policy, or Excluded to leave them off it (an excluded person is not covered by the policy). Who qualifies?

Ownership total: 0%

Operations

Brief description of operations * (at least 7 words)

Gross receipts (annual) *

Total annual payroll *

% Residential *

% Commercial *

% Remodel *

% New Constr. *

% Interior *

% Exterior *

Class Codes & Payroll

Enter each class code you operate under — we'll show the official description as you type. The average hourly wage sets your dual-wage tier.

Why the wage matters: most California construction classes have two codes — one for crews paid below an hourly threshold and one at or above it. The rate difference is significant, and the tier is verified at final audit.

Subcontractors

Important: At the end of your policy, your insurance company audits your payroll to set your final premium. For each subcontractor you used, the auditor will ask for a certificate of insurance (COI) — proof from the sub's own insurance company that the sub carried workers' comp while working for you.
If you can't produce a COI for a sub, that sub's payroll can be added to your policy at audit, and you can be charged additional premium on it. Keep a current COI on file for every sub.

Are you subbing any work out?

No Yes

Do your subcontractors carry their own workers' comp?

No Yes

Do you collect certificates of insurance from every sub?

No Yes

Height & Equipment Exposure

Height exposure between 12–24 feet?

No Yes

Height exposure above 24–40 feet?

No Yes

What is the maximum height exposure?

Are you using any scaffolding?

No Yes

Are you using any scissor lifts?

No Yes

Are you using any cranes?

No Yes

Are you using any booms?

No Yes

Are you using any ladders?

No Yes

Any work below grade?

No Yes

Special Operations

If you answer Yes, the percentage is required.

Are you doing any blasting?

No Yes

Are you doing any drilling?

No Yes

Are you doing any demolition?

No Yes

Are you doing any grading?

No Yes

Are you doing any asbestos work?

No Yes

Are you doing any highway work?

No Yes

Are you doing any scaffold setup?

No Yes

Are you doing any roofing?

No Yes

Are you doing any excavation?

No Yes

Are you doing any exterior framing?

No Yes

Coverage History

Current WC carrier

Renewal / expiration date

Current X-Mod

Expiring annual premium

Any lapse in coverage in the last 3 years?

No Yes

Any claims in the last 5 years?

No Yes

Do you have a written safety / return-to-work program?

No Yes

Do you need a blanket waiver of subrogation?

No Yes

Additional Notes

Submitting this application does not bind coverage. Class code descriptions are from the WCIRB plan for reference — final classification is determined by the carrier and WCIRB.