WORKERS COMPENSATION WORKSHEET

BUSINESS NAME:

FEDERAL ID# SS#

PHONE FAX YRS IN BUSINESS

LOCATION:

ADDRESS

MAILING ADDRESS ( IF DIFFERENT):

ADDRESS

DESCRIPTION OF OPERATIONS:

NAMES OF EACH OWNER AND WHAT % DOES EACH OWN 

                 NAME                                 % OWNED

ARE OWNERS INCLUDED OR EXCLUDED? EXCLUDED INCLUDED

ANY MEDICAL COVERAGE FOR EMPLOYEES?    YES NO

NUMBER OF EMPLOYEES PER CLASS AND PAYROLL

CLASS #EMPLOYEES PAYROLL $

CLASS #EMPLOYEES PAYROLL $

CLASS #EMPLOYEES PAYROLL $