Worker Compensation Review

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Instructions

Items needed to complete this form:

Copy of your current Certifcate of Coverage (COI)
Declaration Page of Current Policy
A Loss Run report or No Loss letter on your company letterhead

Please complete this form to the best of your ability. If you are a start up company and do not have a current policy please enter N/A into the fields that do not apply, the items listed above will not apply either. If you have any questions when completing this form, please reach out to Samantha Long at slong@Tilsonhr.com.

Basic Company Information

Legal Company Name

DBA

FEIN

Years in Business

Organization Type

SIC Code

https://siccode.com/sic-code-lookup-directory

Company Contact Name

Phone Number

General Description of Business

Current Policy Review

Do you have a current Workers Compensation policy?

Yes

What is your current policy number?

Who Is Your Worker Compensation Carrier?

How Long Have You Had This Policy?

What Is The Renewal Date?

What is your anual premium?

Current Certificate of Coverage

3 Years Loss Run Report or No Loss Letter on your Company Letter Head

If you have questions about this letter please reach out to Samantha Long at slong@tilsonhr.com

Current Declaration Page

Reflects each workers compensation class code, annual wages for each code and corresponding rate.

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