Workers Compensation Application

Please complete the information below. Fields marked with * are required.

Business Information

Date

Years in Business

Applicant Name

Legal name of the business

Office Phone

Mobile Phone

Mailing Address

Street, City, State, ZIP (include ZIP + 4 if available)

E-mail Address

Federal Employer ID Number (FEIN)

Format: 12-3456789

Entity Type

Other Entity Type (please specify)

Proposed Effective Date

Proposed Expiration Date

Automatically set to one year after the effective date

Business Physical Location

List every location where you have employees.

Street Address

City

County

State

ZIP Code

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Inspection Contact

Who should the carrier contact to schedule an inspection?

Contact Name

Contact Mobile Phone

Contact E-mail

Individuals Included / Excluded

Partners, officers, and relatives employed by the business to be included in or excluded from coverage.

Name

Date of Birth

Title / Relationship

Ownership %

Included or Excluded

Included

Excluded

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Rating Information — Payroll by Classification

Add one row for each class of work at each location.

Location #

Select the Business Physical Location where this work is performed

Class Code

Start typing a code or keyword. Need help? Search the WCIRB classification database.

Categories, Duties, Classifications

# Full-Time Employees

# Part-Time Employees

Estimated Annual Remuneration / Payroll ($)

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Has the business had prior workers' compensation insurance?

Yes

Select "No" if this is a new venture with no prior coverage.

Prior Carrier Information

Provide information for the past 5 years.

Year

Carrier

Policy Number

Any claims during this policy year?

Yes

# Claims

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Nature of Business / Description of Operations

Description of Operations

Describe your business, operations and products. Manufacturing: raw materials, processes, product, equipment. Contractor: type of work, sub-contracts. Mercantile: merchandise, customers, deliveries. Service: type, location. Farm: acreage, animals, machinery, sub-contracts.

Signature

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, DC, FL, HI, MA, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)

I accept the terms

Referred/Completed by

Document

Maximum file size: 516MB

Applicant's Signature

Clear

If you are human, leave this field blank.

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Workers Compensation Application