Application for Workers' Compensation

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Complete the form below and upload a text or PDF file with the following info:

  1. A completed Acord Application
  2. Currently Valued Loss Runs and Premium Information for the last 3 years
  3. Current NCCI Experience Rating Worksheet
  4. A detailed narrative explaining the operations of the insured
  5. A detailed description of losses in excess of $25,000
  6. A current Financial Statement for risks generating $250,000 or more in premium
  7. Any other information which might help in the underwriting/pricing of the risk
Please click the "Browse" button and navigate to a file on your on your computer.