WORKERS' COMPENSATION APPLICATION
Need Assistance? Call David
Ruiz at 800-866-2682, Ext. 112
SECTION I - APPLICANT INFORMATION
Full Corporate Name:
Federal Employer Identification Number (FEIN):
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
SECTION III - WORKERS COMPENSATION HISTORY
Do you currently carry workers' compensation insurance?
Do you have an experience modifier?
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?