Transcription of Workers’ Compensation Supplemental Application
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Workers’ Compensation Supplemental Application
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: _____ Phone: _____ Claims: _____ Phone: _____ PRIOR PAYROLL & PREMIUM INFORMATION Total Annual Payroll Premium $ Current Year: 20____ Prior Year: 20____ Prior Year: 20____ Prior Year.
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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