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Agency Excel – Forms

Forms

Erie Worker's Comp App

Business Name*
Business Type*
Business Inception Year*
Contact Name*
First Last
Phone*
Email*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Location Address
Same as Mailing

Street Address Address Line 2 City State ZIP Code

Describe Applicant's Operations*
Do you have any additional locations?*
- Yes
- No
Location 2*
Street Address Address Line 2 City State ZIP Code
- Add Location
Location 3
Street Address Address Line 2 City State ZIP Code
- Add Location
Location 4*
Street Address Address Line 2 City State ZIP Code

Coverage Info
Coverage Limits*
Each Accident/Policy Limit/Each Employee
Classification of Operations
Class 1 Description*
Class 1 Payroll*
Annualized Payroll
Class 1 Code
- Add Additional Class
Class 2 Info
Class 2 Description*
Class 2 Payroll*
Annualized Payroll
Class 2 Code
- Add Additional Class
Class 3 Info
Class 3 Description*
Class 3 Payroll*
Annualized Payroll
Class 3 Code

Untitled
- First Choice
- Second Choice
- Third Choice

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