Worker’s Compensation

Please complete all required fields

  • WORKER’S COMP INSURANCE HISTORY

  • **IF YOU DO HAVE THE LOSS RUNS PLEASE UPLOAD WITH THIS APPLICATION**
  • LOSSES

  • All losses/claims require a written description, including nature of injury cause and current status.
  • Employee Information

  • Benefits

  • Type Of Work

  • THIS APPLICATION CONTAINS THE INFORMATION NEEDED TO START YOUR POLICY. IN SOME CASES IT MAY BE NECESSARY TO TRANSFER THIS INFORMATION TO ONE OR MORE CARRIER SPECIFIC FORMS. IF THAT IS NECESSARY WE WILL COMPLETE THEM FOR YOU AND SIGN ON YOUR BEHALF WITH THE INFORMATION FROM THIS APPLICATION.CLIENT AGREES TO INDEMNIFY AND HOLD HARMLESS TOP CONTRACTORS INSURANCE, ANY OF ITS EMPLOYEES AND AGENTS, ALONG WITH ANY OF ITS AFFILIATED COMPANIES FROM AND AGAINST ANY AND ALL CLAIMS ARISING OUT OF OR RELATION TO ANY ALLEGED FAILURE TO ACT ON THE PART OF THE CLIENT WHICH RESULTS IN ANY CLAIM, DEMAND, ACTION, OR CAUSE OF ACTION AGAINST TOP CONTRACTORS INSURANCE SERVICES INC, OR ITS AFFILIATED COMPANIES.
 

Verification