Worker’s Compensation Prefer to fill out by hand? Click here to download a printable version Step 1 of 2 50% Entity Name Email PhoneWebsite Insured Form of Business Individual Corporation LLC Partnership Other Number of PartnersTax ID NumberNCCI Risk ID NumberDate EstablishedYears ExperiencedMailing/billing address City State ZIP Code ParishSelect...Acadia ParishAllen ParishAscension ParishAssumption ParishAvoyelles ParishBeauregard ParishBienville ParishBossier ParishCaddo ParishCalcasieu ParishCaldwell ParishCameron ParishCatahoula ParishClaiborne ParishConcordia ParishDeSoto ParishEast Baton Rouge ParishEast Carroll ParishEast Feliciana ParishEvangeline ParishFranklin ParishGrant ParishIberia ParishIberville ParishJackson ParishJefferson ParishJefferson Davis ParishLafayette ParishLafourche ParishLaSalle ParishLincoln ParishLivingston ParishMadison ParishMorehouse ParishNatchitoches ParishOrleans ParishOuachita ParishPlaquemines ParishPointe Coupee ParishRapides ParishRed River ParishRichland ParishSabine ParishSt. Bernard ParishSt. Charles ParishSt. Helena ParishSt. James ParishSt. John the Baptist ParishSt. Landry ParishSt. Martin ParishSt. Mary ParishSt. Tammany ParishTangipahoa ParishTensas ParishTerrebonne ParishUnion ParishVermillion ParishVernon ParishWashington ParishWebster ParishWest Baton Rouge ParishWest Carroll ParishWest Feliciana ParishWinn ParishEntity address City State ZIP Code ParishSelect...Acadia ParishAllen ParishAscension ParishAssumption ParishAvoyelles ParishBeauregard ParishBienville ParishBossier ParishCaddo ParishCalcasieu ParishCaldwell ParishCameron ParishCatahoula ParishClaiborne ParishConcordia ParishDeSoto ParishEast Baton Rouge ParishEast Carroll ParishEast Feliciana ParishEvangeline ParishFranklin ParishGrant ParishIberia ParishIberville ParishJackson ParishJefferson ParishJefferson Davis ParishLafayette ParishLafourche ParishLaSalle ParishLincoln ParishLivingston ParishMadison ParishMorehouse ParishNatchitoches ParishOrleans ParishOuachita ParishPlaquemines ParishPointe Coupee ParishRapides ParishRed River ParishRichland ParishSabine ParishSt. Bernard ParishSt. Charles ParishSt. Helena ParishSt. James ParishSt. John the Baptist ParishSt. Landry ParishSt. Martin ParishSt. Mary ParishSt. Tammany ParishTangipahoa ParishTensas ParishTerrebonne ParishUnion ParishVermillion ParishVernon ParishWashington ParishWebster ParishWest Baton Rouge ParishWest Carroll ParishWest Feliciana ParishWinn ParishOwner and Percent Owned PhoneDate of BIrth Month Day Year Social Security Number Owner and Percent Owned PhoneDate of BIrth Month Day Year Social Security Number Detailed description of business operationsAny losses in the last 5 years? Yes No Loss HistoryDate of LossLoss Description Add RemoveLiability Limit requested Prior Work Comp Coverage Yes No Carrier Employee BreakdownIncluding or excluding owner for work comp? Including Excluding Total number of employeesTotal payroll excluding ownerIndividuals Included/ExcludedFull NameDOBTitle/RelationshipOwnership %DutiesInc/ExcClass CodeRemuneration/Payroll Add RemovePart Time Clerical/Office: #Full Time Clerical/Office: #Total payroll this class: $Part Time Labor: #Full Time Labor: #Total payroll this class: $Part Time Other: #Full Time Other: #Total payroll this class: $Part Time Other: #Full Time Other: #Total payroll this class: $Part Time Other: #Full Time Other: #Total payroll this class: $Will you use uninsured subs/casual labor? Yes No Amount paid annuallyUninsured Subs Contract Labor Will you use insured subs? Yes No Amount paid annuallyCollect Certificates for subs? Yes No Required to have equal liability limits? Yes No NameThis field is for validation purposes and should be left unchanged. Δ
