Worker’s Comp – Automotive

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Applicant Information
Company Name*
EIN #:*
Contact Name*
Years of Operations*
Email
Phone
Website
Location Full Address*
Mailing Full Address*
Description of Operation*
Do you have payroll?*
- Yes
- No
If yes, Who's in charge of your payroll?
Company*
Contact Name:*
Phone Number:*
Email:*
If no, will you have your payroll with us?*
- Yes
- No

Is Associate Member filling out this form?
- Yes
- No
Associate Name
Associate's Email
Phone
IMPORTANT Disclaimer*
- I've read, understand and accept the following statement.
I Understand that all information provided is subject to verification by way of an underwriting survey or inspection. We must be notified of any significant change in operations or payroll. Terms of insurance coverage may be cancelled for misrepresentation if information provided is inaccurate.
Signature of Applicant*
Date
Email

This field is for validation purposes and should be left unchanged.