WORKERS' COMPENSATION APPLICATION
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Need Assistance?  Call David
Ruiz at 800-866-2682, Ext. 112
SECTION I - APPLICANT INFORMATION
Full Corporate Name:

Street Address:

City:State:Zip:

Entity Type:


Federal Employer Identification Number (FEIN):

Telephone:Fax:E-Mail:

Contact Name:
SECTION II - PAYROLL BY CLASSIFICATION of EMPLOYEE
Classifications Estimated Annual Payroll
$
$
$
$
SECTION III - OWNERSHIP INFORMATION
Please provide the following information on all owners:
Full NameDate of Birth% of OwnershipCorporate Title
Include or Exclude
From Coverage?
SECTION III - WORKERS COMPENSATION HISTORY
Do you currently carry workers' compensation insurance?

Do you have an experience modifier?
If yes, what is is?
SECTION IV - OTHER ITEMS
Do you use any 1099 independent contractors?
Do you have 24-hour exposure?
Do you conduct any of the following training?
Do you have any of the following?
CorporationLLCPartnershipSole ProprietorshipNot Yet Determined
All Therapists
Clerical Office Employees
Sales, Outside or Inside
Other
IncludeExclude
IncludeExclude
IncludeExclude
IncludeExclude
YesNo
YesNo
YesNo
YesNo
Lifting Training
Patient Handling/Transfer Training
Modified Duty / Light Duty
New Employee Orientation
Accident Investigations
Safety Committee
Functional Testing of New Hires