State industrial insurance affrimation compliance 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Business Name, including any 'doing business as' names. Fill in the Type of Business and your Business Telephone Number.
3. Next, provide your Business Address, including City, State, and Zip Code.
4. Input your Federal Identification Number, Social Security Number, and Contractor’s Board License Number.
5. Fill in the Name of Principal Owner and their Telephone Number. Then enter the Principal Owner’s Address details.
6. Select one section under 'Identified as' that applies to your business regarding industrial workers’ compensation insurance or exemptions.
7. Complete the Effective Date of Coverage and Account Number if applicable. If claiming exemption or self-insurance, provide the relevant Effective Date and Certificate Number.
8. Declare your authority to act on behalf of the business by selecting the appropriate business type (Individual, Sole Proprietor, Partnership, Corporation).
9. Print and sign your name as Applicant along with your Title. Ensure a witness from the Business License Office signs as well.
10. If not signing in person, ensure a Notary Public notarizes your signature before submission.

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