Workers Compensation Supplemental Application

← Back to document page

Workers Compensation Supplemental Application (To be Completed with Acord 130 Application )Named Insured:Insured's FEIN:Web Address:Contact Name and Phone NumberInspections:Premium Audit:Claims:())()(---Prior Payroll and Premium InformationCurrent Year:Total Annual PayrollPremium $Prior YearPrior YearPrior YearPrior YearOperations and BenefitsBroker Controlled Account?Please provide a description of the operation:Years in business?:Hours of Operation:toNoYesYesNo# of Shifts:Does the applicant ever allow employees to work more than 3 consecutive 12 hour shifts?

Workers Compensation Supplemental Application (To be Completed with Acord 130 application) Named Insured: Insured's FEIN: Web …

  Applications, Compensation, Worker, Supplemental, Workers compensation supplemental application