Employer Tax Form Packet (Page 2 of 9) in pdf

Employer Tax Form Packet Page 2

Public Partnerships,

LLC Fiscal/Employer

Agent

One Cabot rd. STE 102

Medford, MA 02155

Workers Compensation Insurance Power of Attorney Form

I, ____________________________, hereby appoint Mike McConville, Public Partnerships

(Please print Employer of Record’s Name Here)

LLC, One Cabot rd. STE 102, Medford, MA 02155, (866) 315-3740 to act as my attorney - in-

fact for the

purpose of obtaining and maintaining workers’ compensation insurance for me as the named

insured. The appointed attorney-in-fact has the authority to handle all transactions with the

insurance carrier regarding the workers’ compensation insurance policy issued in my name,

including but not limited to: payment of premium, receiving notices of non-renewal and

cancellation and cooperation with audits.

Signature of Employer: ____________________________________________________

Date: _________________________________________________________________

Employer of Record Name: _______________________________________________

Employer of Record Address (City, State, Zip): _______________________________

______________________________________________________________________

Public Partnerships, LLC

Required

Employer Tax Form Packet Page 2