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:
Zip :
Detailed description of Job Duties to be Performed Under this Code