Your Full Name

Business Name

Mailing Address

City

State

ZIP / Postal Code

E-Mail

Phone

FAX

Business Operations

Employees

Annual Payroll

Experience Modification

Years in Business

Current Insurance Company

Comments

In order for our Certified Work Comp Counselor to do their forensic work, we must have all the pieces of your Work Comp puzzle. Our goal is to keep your efforts at a minimum. To get started here is what we will need:

• Loss Runs (3 to 5 years)
• Experience Modification Worksheet (from state bureau or NCCI)
• Past Work Comp policy declarations (3 to 5 years)

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