Workers' Compensation Supplement

Use when completing a Business Package application.

Call 650-858-1123 for assistance

Business or Contact Name (as listed in Business Package App)

Total Annual Payroll (not including Owners/Officers)

Include or Exclude Coverage for Owners & Officers

You may choose to cover all owners/officers for injury, or exclude them from coverage.

Include Coverage

Exclude Coverage

Owner/Officer Total Annual Payroll

Only required if Owners/Officers included.

Owner/Officer Information

Provide Legal Names, Dates of Birth, Titles, and Duties of all Owners/Officers.

Is Group Health Insurance provided to your employees?

Yes

No

If yes, list Health Provider and Group ID #

Employer Federal Tax ID or Social Security #

Remarks Section

List any additional information.

We will email you with any remaining questions.

Email additional comments to quotes@marketside.net Please include your business name for reference.