Workers' Compensation Application
Contact Name
Prefix
First Name
Last Name
Suffix
Company Name
Full Corporate Name, for example ABC, Inc. DBA Swan Home Care
Email
*
example@example.com
Phone Number
*
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Address (if Different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Save and Return Later - An E-Mail Link Will Be Sent From Which You Can Access the Form at a Later Time
Federal Tax ID Number
Years in Business
Proposed Effective Date
MM/DD/YYYY
Workers compensation is priced by classification of employee. Please help us with estimates of the following:
Estimated Annual Payroll
Home Health Care Professionals (RN, LVN, LPN, Therapist, Etc.)
Home Care Non-Professionals (Aide, CNA, Attendant, Companion)
Clerical Office Employees
Outside Sales
Other
For Each Owner: Name, Date of Birth, Corporate Title and % Ownership
Example: Jane Doe, 7/26/1958, President, 100%
Employee Questions
Yes
No
How Many? (if applicable)
Do you have employees over age 60 or under age 16?
Is a written safety program in operation?
Insurance Information
Are you Currently Insured? Please Select One
Never Insured
Insured Currently
Previously Insured, Not Currently
We need loss runs and current coverage information to get a quote. Please upload what you have available.
Browse Files
A 'loss run' is a report from prior insurers showing any claims and their associated costs
Cancel
of
If you don't have current loss runs, we can help you get them. Please upload declarations pages or a certificate of insurance to get us started
Browse Files
A 'loss run' is a report from prior insurers showing any claims and their associated costs
Cancel
of
May we have permission to access your Experience Modifier from NCCI or other rating authority?
Yes
No
Use the mouse, or your finger if using a touch screen, to sign below
Save and Return Later - An E-Mail Link Will Be Sent From Which You Can Access the Form at a Later Time
Name of Person Signing Application
First Name
Last Name
Submit
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