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APPLICATION FOR WORKERS COMPENSATION INSURANCE
FAST, EASY & SAFE!
ALL INFORMATION SUBMITTED WILL REMAIN CONFIDENTIAL & SECURE

BUSINESS INFORMATION
Company Name		Phone
Street Address		City
State		Zip Code
County		Federal Tax ID
Contact Person		Email
Type of Business: Individual Corporation Partnership Non-Profit Other

ADDITIONAL INFORMATION

Number of Years In Business

Have you ever been insured for Workers Compensation?

Yes No

If yes, please provide information on your workers compensation experience for the past 5 years:

CARRIER	POLICY#	PREMIUM$	PERIOD
			From-
			From-
			From-
			From-

Have you been declined for coverage during that last 12 months

Yes No

If Yes, explain reason:

Please provide a complete, detailed job description of all work performed, and/or
describe your business operations including the products or services sold

Do you employ subcontractors, owner-operators and/ independent contractors? Yes No

LIST YOUR ESTIMATED ANNUAL PAYROLL BY TYPE OF WORK OR DUTIES FOR ALL EMPLOYEES

If you are a corporation with 1 or 2 executive officers who collectively own 100% of the corporation's stock, you have the option to exclude the officers from coverage.
Do you wish to exclude the officer(s)? Yes No

If you are a partnership, LLP, PLLP, LLC, or Sole Propietorship you can elect to bring partners, members or self-employed persons under coverage for a premium that is subject to a minimum & maximum annual remuneration. If Yes, include remuneration for person(s) you wish to bring under coverage below.
Do you wish to include partners, members or self-employed persons? Yes No

Job Title	Job Duties	# of Employees	Annual Payroll

Insert Questions, Comments And/Or Additional Information Here:

DECLARATION & DISCLOSURE
This application shall not be binding on the Underwriters unless and until a contract of insurance is issued and delivered in accordance herewith and then only as the commencement date of said insurance and in accordance with all terms thereof. The Applicant hereby covenants and agrees to and with the Underwriters that the foregoing statements and answers fully and truly represent, to the best of the Applicant's knowledge, all the facts and circumstances with regard to the risk to be insured. The Applicant also agrees that the answers and statements contained herein form the basis and conditions of the insurance.

The Applicant understands that the application can't be signed.

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