Workers Compensation Application


Fields marked with an asterisk (*) are mandatory.
Insured Information
Name of Business:  *
FEIN / SSN:  *
No. of years with Workers' Comp Insurance:  *
Any exposures outside of this state?  *
Phone Number:  *
Contact Email:  *
  Locations / Class Codes
Enter total number of class codes assigned to your FEIN Number::
  State Class Code - Job Description Total Aggregate Payroll per Class Code Total Aggregate Number of Full Time Employees Total Aggregate Number of Part Time Employees Remove