Workers Compensation Application

Please complete the form below

Applicant Name:

Description of Operations:

Mailing Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Type:

Sole Proprietor

Corporation

Partnership

Subchapter "S" Corp

LLC

Joint Venture

Trust

Other

Federal Employer ID Number:

Desired Effective Date:

MM

DD

YYYY

Contact Name:

First Name

Last Name

Phone

(###)

###

####

Email:

Name(s) of Individuals Excluded

PARTNERS, OFFICERS, RELATIVES ( Must be employed by business operations) TO BE INCLUDED OR EXCLUDED (Remuneration/Payroll to be included must be part of rating information section. Include date of birth, title, ownership % and duties or each individual.)