WORKERS' COMPENSATION APPLICATION
Need Assistance? Call David Ruiz at
800-866-2682, Ext. 233
SECTION I - APPLICANT INFORMATION
Full Corporate Name:
Federal Employer Identification Number (FEIN):
SECTION II - PAYROLL BY CLASSIFICATION of EMPLOYEE
Classifications Estimated Annual Payroll
SECTION III - OWNERSHIP INFORMATION
Please provide the following information on all owners:
Full NameDate of Birth% of OwnershipCorporate Title
Include or Exclude
SECTION III - WORKERS COMPENSATION HISTORY
Do you currently carry workers' compensation insurance?
Do you have an experience modifier?
Do you use any 1099 independent contractors?
Do you conduct any of the following training?
Do you have any of the following?