RCFE

Business Details

Supplemental Questions

Business structure*

Name of Business*

Applicant Name*

# Years in Business*

Address*

City*

Zipcode*

E-Mail Address*

Phone Number*

Estimated Annual Payroll*

Effective Date*

# Full Time Employees*

# Part Time Employees*

Federal TAX ID Number or SSN (if Sole Prop)*

Do you currently have Workers' Comp Insurance?*

Any claims in the last 3 years for Workers Compensation?*

Experience Modification Factor % (Default: '1.00')*

Waiver of Subrogation

Owner 1 Full Name*

Title/Relationship*

% of Ownership*

Owner 2 Full Name

Title/Relationship

% of Ownership

Owner 3 Full Name

Title/Relationship

% of Ownership

Are Independent Contractors Used?*

Do you have multiple locations?*

I certify that I am currently licensed and have not had a previous claim in the past 3 years.

Insurance