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State industrial insurance affrimation compliance 2026
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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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