Whether you're starting up or need a competitive quote for renewal Delaney Insurance Agency is here to help.  Complete the information form and submit below for a 24-Hour Indication of Insurance.

Basic Information
Name
Company Name
Address
City	California,    Zip Code

Please supply either a Daytime or Evening Phone Number & best time to call.
Day Time Number:
Evening Number:
Fax Number:
Best Time To Call	Select Morning Afternoon Evening
E-Mail
Federal Tax ID Number
Years in business

Business Description please provide type of business and complete description of operations

Class Code & Payroll Information
Class code 00050037004220032501258528122883307631133179338335743629363236813685372442994361451150225183519051915213522153485403543754455474550655385606564556516216621772287229738075207600761077047720772377278006800880108013801780188033804480618232829383508380839386018742880388108820883188328833883588689014901590239052906090619082908391019102940294039519952195229586	# of Emp	Description:	Payroll: $
Class code 00050037004220032501258528122883307631133179338335743629363236813685372442994361451150225183519051915213522153485403543754455474550655385606564556516216621772287229738075207600761077047720772377278006800880108013801780188033804480618232829383508380839386018742880388108820883188328833883588689014901590239052906090619082908391019102940294039519952195229586	# of Emp	Description:	Payroll: $
Class code 00050037004220032501258528122883307631133179338335743629363236813685372442994361451150225183519051915213522153485403543754455474550655385606564556516216621772287229738075207600761077047720772377278006800880108013801780188033804480618232829383508380839386018742880388108820883188328833883588689014901590239052906090619082908391019102940294039519952195229586	# of Emp	Description:	Payroll: $
Class code 00050037004220032501258528122883307631133179338335743629363236813685372442994361451150225183519051915213522153485403543754455474550655385606564556516216621772287229738075207600761077047720772377278006800880108013801780188033804480618232829383508380839386018742880388108820883188328833883588689014901590239052906090619082908391019102940294039519952195229586	# of Emp	Description:	Payroll: $
Class code 00050037004220032501258528122883307631133179338335743629363236813685372442994361451150225183519051915213522153485403543754455474550655385606564556516216621772287229738075207600761077047720772377278006800880108013801780188033804480618232829383508380839386018742880388108820883188328833883588689014901590239052906090619082908391019102940294039519952195229586	# of Emp	Description:	Payroll: $

Current Workers Compensation Insurance Information
Company Name (not agency)
Policy
Premium amount
Current Exp Mod

Claims Information Please list all workers compensation claims within the prior years and give basic details for the accident including the amount paid.

Additional Comments Please give any additional information you feel appropriate for the quotation.  If you have additional information where there were insufficient fields above such as additional drivers, vehicles, driver histories, etc., please enter them here.

This is a request for quote only, not an application for insurance.