Application For Workers' Compensation Insurance
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1
2Laundry Owners Mutual
701 Rodi Rd - Suite 100
Pittsburgh, PA 15235
APPLICATION
(412) 825-5415
FOR
1(800) 590-4404
(412) 825-5425 (fax)
WORKERS' COMPENSATION INSURANCE
Date
:
#1 -- APPLICANT INFORMATION
Company Name:
Individual
Partnership
- (LP, GP)
DBA:
Limited Liability Corporation
- (LLC)
Street Address:
Suite Number:
Corporation
Corporation
- C
- S
City:
State:
Zip:
Non-Profit
County:
Other
(Explain):
Phone Number:
Fax Number:
State Bureau File Number:
Email:
Number of Years in Business:
#2 -- ADDITIONAL LOCATIONS
[If more than 3 additional locations please list on a separate sheet of paper]
Loc
Name of Facility, Street, City, State, Zip, County
Phone Number
FEIN #
Name:
Street:
1
(Primary)
City:
State:
Zip Code:
Name:
Street:
2
City:
State:
Zip Code:
Name:
Street:
3
City:
State:
Zip Code:
#3 -- CORPORATE OFFICER / PARTNER INFORMATION
[Only Officers of a C-Corp (5% or >) or S-Corp (1% or >) can elect to be excluded from coverage]
Name:
Title:
Name:
Title:
Ownership % :
Included/Excluded:
Ownership % :
Included/Excluded:
Duties:
Duties:
Annual Salary:
Annual Salary:
Name:
Title:
Name:
Title:
Ownership % :
Included/Excluded:
Ownership % :
Included/Excluded:
Duties:
Duties:
Annual Salary:
Annual Salary:
#4 -- INSURANCE DETAILS
[Please provide a Loss History (Loss Runs) for any carrier during the past 4 years. This information can be
obtained by contacting your insurance carrier for those respective years]
Any prior Workers' Compensation coverage
Policy Effective Date
: From:
To:
(mm-dd-yyyy)
cancelled or non-renewed within the past 3 years?
Current Workers' Compensation Carrier
Policy Number
Number of Claims
No
1
Yes
Please Explain:
Prior Workers' Compensation Carriers
Policy Number
Number of Claims
#
1
2
3
#5 -- DESCRIPTION OF OPERATIONS
[Describe your Business Operations. Include materials & machinery, products or services sold]
WC App v15-09
Please Complete Page 2
Page 1 of 2
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