Applicant Information:

THE PEOple Company

Client Underwriting & Onboarding Submission Packet

Where People Power Business
Applicant Information:
Company:
Date:

MonthDayYear
Date
Owner Name:

First NameMiddle InitialLast Name
Eff Date:

MonthDayYear
Date
Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
FEIN:
Year(s) in Business:
States Operating In:
Broker Name:
Broker Information (if any):
Broker Name:
Workers' Compensation Profile:
Description of Operations:
Scope of Work:

Workers' Compensation Payroll by Code Information

Workers' Compensation Loss History Affidavit
I, blanks , do hereby verify and swear thatblank has incurred injuries within the last 36 months.
Please list the injuries and the costs incurred in the table below for the last 36 months: (Note: If there no injuries, write N/A in the table below.)

Current & Previous Coverage Information

Explanation Required:
If an individual claim exceeds >$15,000.00
By signing below, I attest that the claims information provided is accurate to the best of my knowledge. I further attest that no outstanding premiums are owed to any Professional Employer Organization or insurance carrier.
Company Name:
Signature:
Title:
Date:

MonthDayYear
Date
Should be Empty:

Workers' Compensation Loss History Affidavit