Insurance for Worker's Compensation online application:

General Information
Date
Name of Insured
Mailing Address 1
Mailing Address 2
City
State		AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code

Payroll Information

Class Description Payroll # FT Employees # PT Employees 8832 Dentist 8810 Clerical 7380 Drivers   Other

Federal ID#			Tax ID#
					AK, CO, FL, IN, ME, MN, NM, NJ, NY
Experience Modification Factor (if applicable)			Bureau ID
Employer Libility Limits		$100,000/$500,000/$100,000 $500,000/$500,000/$500,000 $1,000,000/$1,000,000/$1,000,000

Coverage Inclusions / Exclusions

Name Title Include / Exclude include exclude include exclude include exclude include exclude include exclude

Risk Management
Number of Years in Business
Incidents are reported upon occurrence directly to the insurance company		yes no
Records are kept of all incident reports		yes no
Are employees hired		Previously Trained Trained Upon Hire
Is appropriate safety equipment used		yes no
Number of Managed Personnel			Number of Eployees
Employees attend regular training seminars		yes no

Loss History

Date of Loss Description Med/Ind Amount Paid

Current Insurance Company			Annual Premium