WORKERS
COMPENSATION
APPLICATION

STATUS OF SUBMISSION

BILLING/AUDIT INFORMATION

LOCATIONS

POLICY INFORMATION

TOTAL ESTIMATED ANNUAL PREMIUM - ALL STATES

CONTACT INFORMATION

INSPECTION

ACCTNG RECORD

CLAIMS INFO

INDIVIDUALS INCLUDED/EXCLUDED

PARTNERS, OFFICERS, RELATIVES (Must be employed by business operations) TO BE INCLUDED OR EXCLUDED (Remuneration/Payroll to be included must be part of rating information section.) Exclusions in Missouri must meet the requirements of Section 287.090 RSMo.

RATING INFORMATION - STATE

PREMIUM

PRIOR CARRIER INFORMATION/LOSS HISTORY

NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS

GENERAL INFORMATION

EXPLAIN ALL “YES” RESPONSES

APPLICABLE IN TENNESSEE AND VERMONT: 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 [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, DC, FL, HI, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)

IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES.

IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, 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, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.

IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.

LOCATION DETAILS CLICK HERE

Los Angeles Office
1701 South Figueroa 1094
Los Angeles, CA 90015

New York Office
1145 1280 Lexington Ave STE 2
New York, NY 10028

Florida Office
6421 N. Florida Ave D-1537
Tampa, FL 33604

North Carolina Office
801 E Morehead St Ste 105 3647
Charlotte, NC 28202

North Carolina Office
4214 West Wendover Ave. 1205
Greensboro, NC 27407

Working with a Professional Employer Organization (PEO) brings expert value to your business in the areas of Human Resources, Payroll, Employee Benefits, and Risk Management. Diamond PEO takes on the administrative responsibilities of your company for you.

ADDRESS

27442 Calle Arroyo, Cottage 45
San Juan Capistrano, CA 92675

PHONE

SOCIAL MEDIA


Working with a Professional Employer Organization (PEO) brings expert value to your business in the areas of Human Resources, Payroll, Employee Benefits, and Risk Management. Diamond PEO takes on the administrative responsibilities of your company for you.

ADDRESS

27442 Calle Arroyo,
Cottage 45
San Juan Capistrano,
CA 92675

PHONE

SOCIAL MEDIA