Transcription of WORKERS COMPENSATION APPLICATION DATE …
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Example: dental hygienist
WORKERS COMPENSATION APPLICATION DATE …
1980-2009 ACORD CORPORATION. All rights 1 of 4 ACORD 130 (2009/09)MONTHLYQUARTERLYSEMI-ANNUALAT EXPIRATIONAUDIT% DOWN:QUARTERLYSEMI-ANNUALANNUALPAYMENT PLANSTATUS OF SUBMISSIONBILLING / AUDIT INFORMATIONQUOTEISSUE POLICYBOUND (Give date and/or attach copy)ASSIGNED RISK (Attach ACORD 133)DIRECT BILLAGENCY BILLBILLING PLANLOC #STREET, CITY, COUNTY, STATE, ZIP CODELOCATIONSOTHER COVERAGESVOLUNTARYCOMPFOREIGN COVMANAGEDCARE & PLAN/SAFETY GROUPADDITIONAL COMPANY INFORMATIONINDEMNITYMEDICALDEDUCTIBLES(N / A in WI)AMOUNT / %(N / A in WI)NORMAL ANNIVERSARY RATING DATENON-PARTICIPATINGPARTICIPATINGRETRO PLANPOLICY INFORMATIONPROPOSED EFF DATEPROPOSED EXP DATEPART 1 - WORKERSCOMPENSATION (States)
17. any other insurance with this insurer? 16. are physicals required after offers of employment are made? explain all "yes" responses. 18. any prior coverage declined / cancelled / non-renewed in the last three (3) years?
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