WORKERS' COMPENSATION APPLICATION
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Need Assistance?  Call David Ruiz at
800-866-2682, Ext. 233
SECTION I - APPLICANT INFORMATION
Full Corporate Name:

Street Address:

City:State:Zip:

Entity Type:


Federal Employer Identification Number (FEIN):

Telephone:Fax:E-Mail:

Contact Name:
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
From Coverage?
SECTION III - WORKERS COMPENSATION HISTORY
Do you currently carry workers' compensation insurance?

Do you have an experience modifier?
If yes, what is is?
SECTION IV - OTHER ITEMS
Do you use any 1099 independent contractors?
Do you conduct any of the following training?
Do you have any of the following?
CorporationLLCPartnershipSole ProprietorshipNot Yet DeterminedOther
All Caregivers - RN, LVN, CNA, Attendants, Etc.
Clerical Office Employees
Outside Sales, Including Supervisory Visits or Assessments
Other
IncludeExclude
IncludeExclude
IncludeExclude
IncludeExclude
YesNo
YesNo
YesNo
Driver Training
Lifting Training
Patient Handling/Transfer Training
Driver Safety Program
Modified Duty / Light Duty
New Employee Orientation
Accident Investigations
Safety Committee
Functional Testing of New Hires