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Workers’ Compensation Supplemental Application

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All Risks, Ltd. National Specialty Programs 10150 York Road, 5th Floor, Hunt Valley, MD 21030 Toll Free: 800-366- 5810 Fax: 410- 828-8179 Contact us at: Workers Compensation Supplemental Application Page 1 of 4 Workers Compensation Supplemental Application (To be completed with Acord 130 Application ) Named Insured: ________________________________________ Insured s FEIN: __________________________________ Insured s Email Address: _________________________________ Web Address:________________________________ ____ CONTACT NAME & PHONE NUMBER Inspections: ________________________________________ ___ Phone: _____________________________________ Premium Audit.

Workers’ Compensation Supplemental Application 06.18 Page 4 of 4 What is the maximum height at which you will work? _____ What is used?

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