FLORIDA WORKERS COMPENSATION APPLICATION

To help us supply you with the most accurate initial quote possible, please answer as many of the following questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only.
Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION

Applicant name:
(Include all subsidiaries & DBA's to be included
in coverage, along with their fein)

    
Mailing Address (including zip code):
(Include principal physical location and all insured entities)
Years in business?
Federal employer ID number:
LOCATIONS
#
Street, City, County, State, Zip Code
POLICY INFORMATION
Proposed eff date:
States:
RATING INFORMATION
Class Code Estimated Remuneration
INDIVIDUALS INCLUDED/EXCLUDED
Partners, Officers, Owners to be included or excluded.
Name Title/
Relationship		 Ownership % Duties INC/EXC Class Code
PRIOR CARRIER
Please forward a recent loss run for the last five years.
Year Carrier & Policy Number
CO:
POL No.:
CO:
POL No.:
CO:
POL No.:
CO:
POL #:
CO:
POL #:
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS
Professional employer organization (PEO)/Employee leasing company
Temporary employment service

Comments/Description:

EMPLOYEES - PLEASE FORWARD A LIST OF EMPLOYEE NAMES
CONTACT INFORMATION
Phone:
Name:





"Savings & Service Has Been Our Policy Since 1950"
14821 South Dixie Highway, Miami, Florida 33176
P 305.238.1000 F 305.255.9643
E info@morrisandreynolds.com I www.morrisandreynolds.com