Epstein Insurance Services
Business and Personal Insurance for California residents.
P.O. Box 7851, Riverside, CA 92513


Office: 951-687-1012
Fax: 951-688-6530
E-mail: Quote@urs2.net

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Business Insurance Quote
name of Business:
Contact name:
E-mail:
Street Address:
City:
State:
  Zip:
County:
Nature of business:
More than one location?:  Yes   No
If yes, where?:
Number of full time employees (30+ hrs/week):
Any employees paid by commission or paid as full-time contractors?:  Yes   No
Any COBRA participants previously employed by you?:
Percent of costs to be paid by employers:  
   % of employee costs:
   % of dependent costs:
type of employees to be quoted:   All   Management   Hourly   Salary   Non-Union
Employees living out of state?   Yes   No
Desired Effective Date:
   
Business Phone:
   Fax:
Best time to call:   AM PM

Current Insurance Company (not agency):

Company name:
Policy Exp. Date:
What type of coverages do you currently have: Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
 Group Life
Professional Liability
Workers' Compensation
Other  

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