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Workers Compensation Insurance Application
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Business the Layout
Name
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First
Last
Phone
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Email
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Preferred Method of Contact
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City, State (Illinois only)
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Business Details
Legal Business Name
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FEIN
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Business Address
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Type of Business / Industry
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Payroll Information
Total Number of Employees
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(full time/part time)
Job Classifications
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Estimated Annual Payroll per Class
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Coverage Details
Any subcontractors used?
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Yes
No
Do subcontractors carry their own workers comp?
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Yes
No
Claims History
Any workers comp claims in the past 5 years?
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Yes
No
Consent
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