State industrial insurance affrimation compliance: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Business Name, including any 'doing business as' names. Fill in the Type of Business and your Business Telephone Number.
Next, provide your Business Address, including City, State, and Zip Code.
Input your Federal Identification No., Social Security No., and Contractor’s Board License No.
Fill in the Name of Principal Owner and their Telephone Number. Then, complete the Principal Owner’s Address details.
Select one section under 'Identified as' that applies to your business regarding industrial workers’ compensation insurance or exemptions.
Declare your authority to act on behalf of the business by filling in the Name of Applicant, their Telephone Number, and Residence Address.
Finally, sign the document in front of a Business License Office Employee or have it notarized if necessary.

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