Workers’ Compensation

Please complete the form below. All fields are required.
Company Name*
Address*
Phone*
Cell*
Fax*
Contact Name*
E-mail Address*
Contractors License Number

Classification: Group 1
4 Digit Code (group 1)
Description (group 1)
Estimated Annual Payroll (group 1)
Classification: Group 2
4 Digit Code (group 2)
Description (group 2)
Estimated Annual Payroll (group 2)
Classification: Group 2
4 Digit Code (group 3)
Description (group 3)
Estimated Annual Receipts (group 3)
Additional Groups

General Information
Federal Tax ID #
Current X Mod
Current Carrier
Renewal Date
Notes
Comments
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We're here...
ready to help!

Our team:

Bob Herzog bio email
Chris Hardiman bio email
Kelly Hillman bio email
Susan Groff bio email
Susan Eppard bio email
Karen Rodriguez bio email
Caitlin Looney bio email
Joyce Wisgerhof bio email
Linda Rose LPRT bio email
Sara Sequeira bio email
Marchelle Mattson bio email

Herzog Insurance Agency

Bus: (925) 734-0530

Fax: (925) 249-7335

235 Main Street

Pleasanton, CA. 94566

Map to our office