Work Comp
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Entity Name & DBA
FEIN #
What type of business are you?
Dispensary
Grow
Processor - Lab
Processor - Edibles
Transportation
Other
Estimated (Non-Owners) Payroll for the next 12 Months
Number of Full Time Employees
Number of Part Time Employees
Additional Notes
Submit
Should be Empty: