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Employees:
1. Job
Description
Amount of Employees
(Full)
(Part)
Payroll (Annual)
2. Job
Description
Amount of Employees
(Full)
(Part)
Payroll (Annual)
3. Job
Description
Amount of Employees
(Full)
(Part)
Payroll (Annual)
Owners:
1. Name
Ownership%
Date of Birth
Payroll(Annual)
Include or Exclude
Social Security #
2. Name
Ownership%
Date of Birth
Payroll(Annual)
Include or Exclude
Social Security #
3. Name
Ownership%
Date of Birth
Payroll(Annual)
Include or Exclude
Social Security #
Do you lease
your employees?
Any work performed
underground or above 15 feet?
Are you employees
covered under a group health policy
Do any of your
employees travel out of state?
Is there any current
or anticipated debt for unpaid premiums owed to any previous workers
compensation provider?
Is there any
volunteer or donated labor?
Any employees with
physical handicaps?
Does business engage
in any other type of business?
Please explain all
Yes Answers:
Have you had any
workers compensation claims in the last 3 years?
Date of Loss
If yes please
describe below and we need loss runs for the last three years:
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