Workers’ Compensation Supplemental Application

Step 1 of 5

20%
  • Contact Name and Phone Number

  • Prior Payroll and Premium Information

  • TOTAL ANNUAL PAYROLL
  • TOTAL ANNUAL PAYROLL
  • TOTAL ANNUAL PAYROLL
  • Customer Profile

  • FOR CORPORATIONS, PLEASE IDENTIFY THE FOLLOWING OFFICER AND OWNERSHIP INFORMATION: (Note that ownership must total 100%)