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WORKERS COMPENSATION APPLICATION

WORKERS COMPENSATION APPLICATION 2025

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The document is a Workers Compensation Application form designed for non-broker accounts, primarily used by businesses to apply for workers' compensation insurance. It includes sections for applicant information, policy details, billing plans, employer's liability, and additional coverage options. The form also requires information about the nature of the business, employee classifications, prior carrier information, and general safety practices. It emphasizes the importance of providing accurate information to avoid penalties related to fraudulent insurance acts.

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