• Workers' Compensation Application

  • Applicant and Business Information

  • Format: (000) 000-0000.
  • Requested Effective Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Owner Information

  • Include or Exclude Owner from Coverage?*

  • Business Operations and Exposure Questions

  • Do you own, operate, or lease any aircraft or watercraft?*
  • Have past, present, or discontinued operations involved storing, treating, discharging, applying, disposing of, or transporting hazardous materials?*
  • Do employees perform any work underground or above 15 feet?*
  • Do employees perform any work on cell towers?*
  • Do you engage in any other type of business?*
  • Do you use subcontractors?*
  • Do you sublet any work without obtaining Certificates of Insurance?*
  • If you are a construction business, do executive supervisors have direct supervision of labor?
  • Do you use volunteer or donated labor?*
  • Do you exchange labor with any other business or subsidiary?*
  • Do you lease employees to or from other employers?*
  • Do you operate as a temporary staffing company?*
  • Have you had any tax liens or bankruptcy within the last 5 years?*
  • Do you have a written safety program in operation?*
  • Have you had any workers' compensation losses greater than $25,000?*
  • Do you have multiple named insureds?*
  • If yes, are the multiple named insureds combinable?
  • Do you provide an employee health plan?*
  • Do you have an employee wellness program?*
  • Do you have a return-to-work program?*

  • Remarks and Signature

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: