Workers' Compensation Insurance

GEMS Insurance offers competitive prices with safety and loss control to keep your premiums going down, not up.

Inquiry Form

If you would like GEMS Insurance to quote an insurance package for workers' compensation, we invite you to complete the following form. Please fill in all fields applicable to your request. A comment area is provided at the bottom of the form for you to ask questions or clarify your inquiry. If your browser does not support forms, feel free to E-Mail us.

Note: We serve only California.

Contact Name

Business Name

DBA

Street Address

City   State   Zip

Phone Number
Best Time to Call   AM   PM

Fax   E-Mail

FED ID#

Current Carrier

Renewal Date

Experience Modification   Number of Employees

Employees Covered by Health Insurance?   Yes   No

Classification Code   Annual Payroll

Classification Code   Annual Payroll

Classification Code   Annual Payroll

Classification Code   Annual Payroll

Classification Code   Annual Payroll

Number of Locations

Any Locations Outside CA?   Yes   No

Do You Have Current Loss Runs?   Yes   No

Comments/Questions




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