Comparison

Send the facts. We will put them next to the program.

This is not an online bind. It is how an independent agency starts an honest quote — payroll, class codes, and what you currently pay.

First nameLast name

Business name

PhoneEmail

CityIndustry

Employee countAnnual payroll

Current annual premium (optional)Current carrier (optional)

Current declarations page (optional)PDF or a photo of your current work-comp dec page. Optional — you can also bring it to the discovery meeting.

What you already haveHR person on staffPayroll in-house or with a vendorSafety / risk hire

Preferred follow-up

PhoneEmail

Anything we should know

Submitting this form does not bind coverage. It emails Driscoll Insured so Kerry can start a comparison. California License #0B99775.