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Workers Compensation Application Form
Workers Compensation Application Form
COMPANY INFORMATION
Applicant Name
Address
City
State
ZIP  
Yrs. In Bus.
SIC

Individual   Partnership   Corporation   Subchapter "S" Corp

OTHER:


Federal Employer ID Number:
LOCATIONS
If applicant is employee leasing company, the client's company name should be included with the address.
List applicants and their information here.
#         LEASING CO? (YES OR NO)         STREET, CITY, COUNTY, STATE, ZIP CODE

POLICY INFORMATION
             Proposed EFF Date: 
             Proposed EXP Date: 
Normal Anniversary Rating Date: 

OTHER OVERAGES:   U.S.L. & H.     Voluntary Compensation
RATING INFORMATION
CLASS CODE CATEGORIES,
DUTIES, CLASSIFICATIONS
# OF
EM-
PLOYEES
ESTIMATED
REMUNERATION
FOR NEXT
POLICY PERIOD

Specify Additional Overages / Endorsements:


INDIVIDUALS INCLUDED / EXCLUDED
Partners, officers, relatives to be included or excluded.
# NAME D.O.B. TITLE/
RELATIONSHIP
OWNER-
SHIP %
DUTIES INC/EXC CLASS CODE REMUNERATION
PRIOR CARRIER INFORMATION/LOSS HISTORY
Provide Information for the Past 5 Years and Use The Remarks Section For Loss Details
YEAR CARRIER & POLICY NUMBER ANNUAL PREMIUM MOD # CLAIMS AMOUNT PAID RESERVE



NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS
Give comments and descriptions of business, operations and products: Manufacturing -- raw materials, processes, product, equipment, Contractor -- type of work, sub-contracts, Mercantile -- merchandise, customers, deliveries, Service -- type, location, Farm -- acreage, animals, machinery, sub-contracts.

EMPLOYEES
List Employees Here:
GENERAL INFORMATION
Check All That Apply

1. DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT?

2. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVED) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc.)

3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?

4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER?

5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS?

6. ARE SUB-CONTRACTORS USED?

7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INS.?

8. IS A FORMAL SAFETY PROGRAM IN OPERATION?

9. ANY GROUP TRANSPORTATION PROVIDED?

10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?

11. ANY PART TIME OR SEASONAL EMPLOYEES?

12. IS THERE ANY VOLUNTEER OR DONATED LABOR?

13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS?

14. DO EMPLOYEES TRAVEL OUT OF STATE?

15. ARE ATHLETIC TEAMS SPONSORED?

16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE?

17. ANY OTHER INSURANCE WITH THIS INSURER?

18. ANY PRIOR COVERAGE DECLINED/CANCELLED/NON-RENEWED (last 3 years)?

19. ARE EMPLOYEE HEALTH PLANS PROVIDED?

20. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY?

21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYEES?

22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME?

23. WHAT ARE YOUR ESTIMATED ANNUAL REVENUES?
CONTACT INFORMATION
INSPECTION:
PHONE:
 NAME:
ACCTNG RECORD:
PHONE:
 NAME:
CLAIMS INFO:
PHONE:
 NAME:
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Your Email Address:
  

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