(Min. 5years)
(Please provide a copy of the most recent payroll invoice that matches the gross payroll amount total, broken out by class codes).

Please provide a breakdown of Hazard Groups based on class codes utilized during the year prior to this submission:

Hours of operation:

It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers’ compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines, and denial of insurance benefits. Any person who knowingly, and with intent to defraud any insurance company or another person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

By signing this document you are authorizing SUNZ Insurance Company to request and be furnished Experience Modification Worksheet(s)/Risk Snapshot(s), from NCCI, relating to the entity named above.

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