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?* ---YesNo Mailing Address* Location 1* Location 2 Officer Name Title % of Stock Included/Excluded Operation/Nature of Business* Operation includes driving?* ---YesNo Driving Frequency? ---DailyWeeklyMonthly Driving Radius? ---10-25mi25-50mi50-100mi+100mi # of Drivers? ---12345678910+15+20+25+30+35+40+45+50+55+60+65+70+75+80+85+90+95+100+ Any losses in the past 5 years?* ---YesNo Do you provide group health coverage for your employees?* ---YesNo Class Codes Description Payroll # of Full-Time # of Part-Time Payroll Information Premium Information Current Year Prior Year Prior Year