WORKERS COMPENSATION APPLICATION

DATE

AGENCY	APPLICANT NAME	Underwriter
AGENCY ID	TAX ID / RISK ID?	LEGAL STATUS

STATUS OF SUBMISSION

LOCATIONS

LOC#	STREET, CITY, COUNTY, STATE, ZIP CODE
	LOCATION

POLICY INFORMATION

PROPOSED EFF DATE

PROPOSED EXP DATE

LIMITS

RATING INFORMATION

STATE	LOC#	CLASS	DESC	CATEGORIES, DUTIES, CLASSIFICATIONS	EXPOSURE	RATE	PREMIUM

		ADDITIONAL ENDORSEMENTS