Worker’s Compensation Prefer to fill out by hand? Click here to download a printable version Step 1 of 2 50% Entity NameEmailPhoneWebsite Insured Form of BusinessIndividualCorporationLLCPartnershipNumber of PartnersTax ID NumberNCCI Risk ID NumberDate EstablishedYears ExperiencedMailing/billing addressCityStateZIP CodeParishSelect...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 addressCityStateZIP CodeParishSelect...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 OwnedPhoneDate of BIrth MM DD YYYY Social Security NumberOwner and Percent OwnedPhoneDate of BIrth MM DD YYYY Social Security NumberDetailed description of business operationsAny losses in the last 5 years?YesNoLoss HistoryDate of LossLoss Description Liability Limit requestedPrior Work Comp CoverageYesNoCarrier Employee BreakdownIncluding or excluding owner for work comp?IncludingExcludingTotal number of employeesTotal payroll excluding ownerIndividuals Included/ExcludedFull NameDOBTitle/RelationshipOwnership %DutiesInc/ExcClass CodeRemuneration/Payroll Part 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?YesNoAmount paid annuallyUninsured SubsContract LaborWill you use insured subs?YesNoAmount paid annuallyCollect Certificates for subs?YesNoRequired to have equal liability limits?YesNo
