Applications / Forms
Please print, fill out, sign, and submit all
pages to MOC 2006 - 2007
2008 - 2009 CHSA Application & CTBL Participation Agreement
CHSA Workers Compensation Insurance Application
Contact Info:
John Patrick Unick - President
Phone: (415) 357-9219
Fax: (415) 957-0577
Email
Sara Przemielewski - Supervisor
Phone: (415) 357-9234
Fax: (415) 957-0577
Email
Frankie Spitaleri - Account Executive
Phone: (415) 357-9229
Fax: (415) 957-0577
Email
MOC Insurance Services
44 Montgomery Street, 17th Floor
San Francisco, CA 94104
Toll Free: (800) 951-0600
Phone: (415) 957-0600
Fax: (415) 957-0577
General
Email
Mail To: Or
Fax To:
MOC Insurance Services (415)
957-0577
Attn: CHSA
44 Montgomery Street, 17th Floor
San Francisco, CA 94104
Please include three years of detailed loss history from your prior workers’
compensation insurance carrier if new to the program.
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