Workers' Compensation Application

Name

Contact Information

Address

Current Work Comp Carrier

Policy Expiration Date

Employers Liability Limits Requested ($500,000 or $1,000,000)

NCCI Risk ID

NCCI Experience Modifier

NCCI Rating Effective Date

Class code #1

Code 1 Description

Code 1 Number of Employees

Code 1 Estimated Annual Payrol

Code #2 Class code

Code 2 Description

Code 2 Number of Employees

Code 2 Estimated Annual Payroll

Class Code #3 Class code

Code 3 Description

Code 3 Number of Employees

Code 3 Estimated Annual Payroll

Class Code #4 Class code

Code 4 Description

Code 4 Number of Employees

Code 4 Estimated Annual Payroll

Class Code #5 Class code

Code 5 Description

Code 5 Number of Employees

Code 5 Estimated Annual Payroll

Any worker's comp claims in the last three years (Y or N)

Type of business operation?

Name of Business:

LLC, Corporation or Individual:

Mailing address:

Physical address:

Will the owners be included or excluded?

Please provide all owners names and percentage of ownership:

Additional Comments