Workers Comp Online Form

Proposal Form

Legal Entity Name

Contact Name

Contact Email

DBA Name

Address

City

State

Zip

Contact Phone

Contact Fax

Years in Business

FEIN

Entity Type IndividualPartnershipCorporationLLCOther

Payroll By Classification Code

You may have more than one classification code. The following should be on the 2nd and 3rd page of your current WC policy.

Class Code

Payroll

No.of Employees

Experience Modification

Current Carrier

Current Premium

Renewal Date

Limits
100/500/100500/500/5001,000/1,000/1,000

Officers are
IncludeExclude from Coverage

Losses (past 3 years)
NoneYes(Explain)

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