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WORKERS COMP INSURANCE FORM

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Type of Business: Sole Proprietor Corporation Partnership LLC
Contact Person:*
Email Address:*
Phone Number:*(xxx-xxx-xxxx)
Fax Number:(xxx-xxx-xxxx)
Address:
 
City:
State:
Zip:
Annual Gross Revenue:$
Federal Employer Identification Number:
Number of Locations:
Own or Lease Office: Own Lease
Number of Owners or Officers:
Description of Business Operations:
Currently have Worker's Comp Insurance: Yes No
If Yes, when does Worker's Comp Expire:
If Yes, who is Worker's Comp With:
Years in Business:
Claims in last three years: Yes No
If Yes, list claims details:
Number of Employees:
Annual Gross Payroll:$
Bankruptcies or Tax Leins
in past 5 years:		 yes no
 
 
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