Physician-Authorization-Return-to-Work-Form-and-Letter[1]

Are You an Agent?

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Contact Information

Full Name*

Phone*

Email*

Business Information

Business Name*

Years In Business*

FEIN or SSN*

Legal Structure of Your Business*

Number of Employees*

Primary Address of Business*

Business Class Code(s) (Add as Many As Needed)*

Policy Information

Do You Want to Include Owners/Officers?*

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Policy Effective Date*

Does Your Business Current Have Work Comp?*

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How Long Has Your Business Had Work Comp?*

Has Your Business Had Any Work Comp Claims in the Past 3 Years?*

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Contact Information

Agent Full Name

Agency Name

Agency Address

Agent Phone

Agent Email

Please upload the following documents:

Agent License

Agency License

W-9 Form

E & O Coverage Verification