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Worker's Compensation Application


Name:
DBA:
Entity:
Cell Phone:
Work Phone:
Mailing Address:
Physical Address:
Email:

Business Information

Federal Employer ID Number:
How Do you play your Employee?
Year Started or Owned:
Years Experience:
Open 24 hours?	Yes No
Approximate Annual Payroll:
Full-Time Employees:
Part-Time Employees:
Business Description:

Employer's Liability

Each Accident
Disease-Policy Limit
Disease-Each Employee

Individuals Excluded/Included

If there is more than one individual, please list it under comments/remarks.

Name
Birthdate:
Title:
Ownership %:
Duties:

Prior Insurance Information

Prior Insurance Co.:
Prior Policy Number:
Prior Effective Date:
Prior Expiration Date:

Losses

Any Losses within 3 years?	Yes No
Loss History
Loss Description

Other Questions

How did you hear about us?

Comments/Remarks:

News & Events