Workers’ Comp Application

S. Philips Surety & Insurance Services Inc.

22647 Ventura Bl #349, Woodland Hills, CA 91364
www.spbonds.com (818) 715-7133

Workers Compensation Application

Insured Legal Name*

Insured DBA*

Proposed Effective Date*

Policy Expiration Date*

X-Mod

Contact Person/Title*

Federal Tax ID*

Phone Number*

Fax

Email*

Years in Business*

Number of Locations*

Operating Outside of US?*

Mailing Address*

Location 1*

Location 2

Operation/Nature of Business*

Operation includes driving?*

Driving Frequency?

Driving Radius?

# of Drivers?

Any losses in the past 5 years?*

Do you provide group health coverage for your employees?*