Insured Solutions
Insured Solutions

Code Request Form

  Worker’s Compensation Code Addition Request
Client Name:
Request Date:  
Requested By:
 
  WC Information
WC Code Requested (If Known)
WC State:
Effective Date:
 
Number of Employees Working Under Requested Code:
Combined Gross Annual Payroll:
Physical Location Where Duties Will be Performed:

Street Address:
City:
State:
Zip :
Detailed description of Job Duties to be Performed Under this Code
 
x