WORKERS COMP APPLICATION
OWNER/OFFICER/AFFILIATE WORKERS COMPENSATION REJECTION/EXCLUSION/INCLUSION
BUSINESS NAME
NATURE OF BUSINESS
Please describe the business oeprations
BUSINESS EIN #
Please Print Full Name
YEAR BUSINESS ESTABLISHED
/
Month
/
Day
Year
Date
CONTACT PERSON
Please Print Full Name
EMAIL ADDRESS
PHONE NUMBER
Format: (000) 000-0000.
TITLE
TOTAL NUMBER OF EMPLOYEES ( FT / PT)
TOTAL PAYROLL ANNUALLY
DONOT INCLUDE THE PAYROLL OF OWNERS/ OFFICERS IF YOU DONNOT WANT COVERAGE FOR OWNERS / OFFICERS
Effective Date of Coverage
/
Month
/
Day
Year
Date
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