Commercial Workers Comp Change Request

Policy Information:
Insured name
Address
City
State*
Zip
Policy number
Policy inception date
Policy expiration date
Effective date of change
Workers Compensation Rating Information:
Type of change
State*
Location
Class code
Describe code
Categories, duties, classifications
Number of full time employees
Number of part time employees
Estimated annual remuneration
53 Loveton Circle, Suite 120 • Sparks, MD 21152
Phone • 1.800.926.8085 • 410.472.1620 • Fax • 410.472.1897

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