Statement Of Workers Compensation Insurance Form printable pdf download

Statement Of Workers Compensation Insurance Form

Talbot County Health Department, Office of Environmental Health

Statement of Workers Compensation Insurance

Maryland Annotated Code, Health-General Article, § 1-202 requires that an

employer must file with the issuing authority:

(1) a certificate of compliance with the Maryland Workers Compensation Act;

(2) a workers’ compensation insurance policy or binder number before any

license or permit is issued.

Please mark the option that best applies, provide the requested information,

sign and date the form, and return it with the attached application.

___

I have Workers Compensation Insurance

Insurance Company ________________________________

Policy or Binder Number _____________________________

___

A copy of the Certificate of Compliance is attached or is on file with this

office from previous licensure periods.

___

Other: _________________________________________________________________

Signature: _________________________________

Date: _______________________

Printed Name: _____________________________

Title: _________________________

Business Name: ______________________________________________________________

Statement Of Workers Compensation Insurance Form