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