New Company Form

Which location will you be working with

Anaheim

Cerritos

Both

Company Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Primary Contact

Email

Employer Phone Number

Number of Employees

Add Additional Authorizing Contacts

Are we going to take care of your work related injuries?

Yes

No

Do you require occupational medicine services? (COVID-19, Drug screening, Physical, PFT, etc.)

Yes

No

Does your company prefer our Bill Direct option?

Yes

No

This option allows your company to avoid your insurance, we offer a 30% discount off the entire work injury bill per case. We suggest this option if your company prefers to pay directly. For more information, give us a call (562) 202 - 8556

Name of Worker's Comp Insurance

Policy Number

NEW COMPANY FORM

New Company Form