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