Transcription of Workers Compensation Supplemental Application
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Workers Compensation Supplemental Application
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 …
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SUPPLEMENTAL TYPE CERTIFICATES, AIRWORTHINESS COMPLIANCE CHECKLISTS FOR, AIRWORTHINESS COMPLIANCE CHECKLISTS FOR COMMON, SUPPLEMENTAL TYPE, CONTRACTORS SUPPLEMENTAL APPLICATION, Supplemental, CONTRACTOR’S SUPPLEMENTAL APPLICATION, Supplemental Nutrition Assistance Program SNAP, Supplemental Nutrition Assistance Program (SNAP) Documentation