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  Workers Compensation Application
 
Fields marked with an asterisk (*) are mandatory.
  Insured Information
Name of HCF Agent Assisting You:  *
Name of Business:  *
FEIN / SSN:  *
No. of years with Workers' Comp Insurance:  *
Any exposures outside of this state?  *
Phone Number:  *
Contact Email:  *
  Locations / Class Codes
# of Locations:
  State Class Code - Job Description Payroll Full Time Employees Part Time Employees Remove
 
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