Form Cra - Combined Registration Application For State Of Delaware Business License And/or Withholding Agent - Division Of Revenue Page 25

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DELAWARE DEPARTMENT OF LABOR
OFFICE OF WORKERS’ COMPENSATION
On behalf of the company/individual named below, I (we) certify that the workers’
compensation insurance coverage is in effect for all employees as required under the
provisions of the workers’ compensation laws of this state.
Name of Employer
_______________________________________________
Fed. E.I./S.S.#
_______________________________________________
Address
_______________________________________________
City, State, Zip
_______________________________________________
CHECK THE APPROPRIATE LINE:
___
I/we have no employees
___
I/we have employees (complete insurance information below):
Name of Insurance Carrier _____________________________
Construction Industry Only:
___ Sole proprietor/partner working as an independent contractor
pursuant to 19DelC§2311:
___
Provide name of insurance carrier (see above)
___
Covered under general contractor’s policy
___
Limited liability corporation (LLC) maximum 4 members
Under penalties of perjury
I (we) declare that this document
is true and correct.
_________________________________
Signature
__________________________________
Title/Date
Division of Revenue is to forward a completed copy of this form to the Office of Workers’ Compensation.
For assistance in completing this form please contact the Office of Workers’ Compensation at:
Wilmington 302-761-8200
Milford 302-422-1392

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