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Workers' Compensation -
Western Region/CA




Tools And Applications

Download everything you need for a complete submission.


Workers Compensation - Western Region/CA


Submission Requirements
Submission Checklist

Applications
Broker of Record Letter – WC – Quote Only
Confidential Request For Ownership Information - Form (ERM-14)
Confidential Request For Ownership Information - Instructions
IRS Form W-9 (Request For Taxpayer ID No. and Certificate)
Loss Run Request
Nursing Home Application
Questionnaire - Auto Dismantlers
Questionnaire - Health Care Services
Questionnaire – New Venture
Questionnaire – Tow Trucks
Supplemental Trucking Application
Supplemental Workers Compensation Application
Temporary Staffing Program Supplemental Application
Waiver of Subrogation Worksheet - Specified Basis





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© 2015 5Star Specialty Programs is a division of and operates under the licenses of CRC Insurance Services, Inc. CA Lic No 0778135. No claim to any government works or material copyrighted by third parties. Nothing in this communication constitutes an offer, inducement, or contract of insurance. Financial strength and size ratings can change and should be reevaluated before coverage is bound. This material is intended for licensed insurance agency use only. This is not intended for business owner or insured use. If you are not a licensed agent please disregard this communication. 5Star Specialty Programs supports a diverse workforce and is an Equal Opportunity Employer who does not discriminate against individuals on the basis of race, gender, color, religion, national origin, age, sexual orientation, gender identity, disability, veteran status or other classification protected by law. Drug Free Workplace.