Workers Comp | PitmanInsurance

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Workers Compensation

POLICY INFORMATION

Proposed Effective Date

APPLICANT INFORMATION

First name

Last name

Address

Company Name

COMPANY TYPE

Corporate

Individual

Joint Venture

Not For Profit

Partnership

LLC

If LLC Number of members

Years in Business

Prior Coverage

Yes

No

CONTACT INFORMATION

Contact Name

Office Phone

Cell Phone

Email

Federal Employer ID Number

PREMISES INFORMATION

Street

City

County

State

ZIP

LOSS HISTORY

Check if none

TYPE/DESCRIPTION OF OCCURANCE OR CLAIM

EMPLOYER'S LIABILITY

Each Accident

Disease-Each Employee

Disease-Policy Limit

INDIVIDUALS INCLUDED / EXCLUDED

Name 1

DOB

Title/Relationship

Ownership % 1

Class Code 1

Remuneration / Payroll

Include/Exclude 1

Include

Exclude

Add another individual

Add another individual

Remove

RATING INFORMATION

Employee Category, duties, classifications - 1

No. Employees full time

No. Employees part time

Add more Categories

Add more Categories

Remove

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