HOME HEALTH WORKERS' COMPENSATION
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SECTION I - APPLICANT INFORMATION
Full Corporate Name:
Federal Employer Identification Number (FEIN): Years in Business:
SECTION II - PAYROLL BY CLASSIFICATION of EMPLOYEE
Classifications Estimated Annual Payroll
SECTION III - OWNERSHIP INFORMATION
Please provide the following information on all owners:
Full NameDate of Birth% of OwnershipCorporate Title
Include or Exclude
SECTION III - WORKERS COMPENSATION HISTORY
Do you currently carry workers' compensation insurance?
Do you have an experience modifier?
Do you use any 1099 independent contractors?
Do you have 24-hour exposure?
Do you conduct any of the following training?
Do you have any of the following?