Miller Insurance Brokerage, Inc.

Providing ALL your Insurance needs into the next millennium!

WORKERS COMPENSATION INSURANCE
SHORT FORM APPLICATION

NAME
DBA

LOCATION(S):        
Address City County State Zip

Phone Number   Contact Person

State Experience Mod - This Year   Previous Year

Class Code(s) Payroll $

No. of Full Time Employees Employer Paid Health Plan


Mark One:

Corporation

S-Corporation

Sole Proprietorship

Partnership

Fed ID No.

36-

 NCCI ID #
Present Carrier Expiration Date
Policy Number Premium


: Each Accident Disease - Policy Limit Disease - Each Employee
Liability Limits:

Check All That Apply:

Any Group Transportation Provided?

Is there volunteer or donated labor?

Do you lease employees from other employers?

Any work performed on barges, vessels, docks, bridges over water?

Any work performed underground or above 15 feet?

Does applicant own, operate or lease aircraft/watercraft?

Do/Have past present or discontinued operations involve(d) storing, treating, discharging, applying, disposing or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)?

12318 S. Cicero Avenue Alsip, IL 60803 708/371-3700 708/371-3705