Products: OREGON WORKERS COMPENSATION APPLICATION

Date you want coverage to begin:

Applicant Name

Contact Person

Mailing Address

Phone:

Best time to call you:

Fax #:

Email:

Location address if different from above:

Are there any other location addresses?

Yes      No

If yes, what address?

The name of your business
(exactly as you want it to appear):

Date business began:

Sole proprietor      Partnership
Corporation     LLC
Other:

Federal Employer ID or SS #

Owners:

Name

% Owned

Brief description of business (What specific types of jobs does your business do?):

If contractor, what is your Oregon contractor
registration number:

What percentage of your work is:

Residential?
Commercial?

Class or job description of employees:

Number of employees:

Estimated annual payroll:

Is there more than one class of employees?

Yes      No

If yes, provide:

Description

Number of employees

Payroll

Description

Number of employees

Payroll

If you have had prior workers compensation coverage:

Name of insurance company:

Date coverage began with this company:

Annual renewal date:

What is the current experience modification, if any?

If coverage cancelled or non-renewed, why?

We need details of:

How much experience you have had in managing employees

Any claims you have had

Any work your employees would do outside the state of Oregon

Of the main hazards of the business

Of what procedures your business uses to enhance employee safety

Of what controls are in place to protect employees from injury