Workers Compensation Step 1 of 5 20% Name Email Phone Business Name Business Address Description of Operation(s)How many years are you in business under this name? How many years of experience do you have in this industry? Did you have any worker’s compensation claims with ANY insurance companies within the last 3 years? Yes No How many claims 1 2 3+ Do you have a business location or a home office? Business Location Home Office Do you rent or own this location? Rent Own What is the total estimated annual payroll? Total number of employees working for you?Total ## of Males# of Females List of Employee Positions, Descriptions of Duties, # of Employees in this position, payroll per employeeEmployee PositionsDescriptions of Duties# of Employees in this positionpayroll per employee
