ROOFING CONTRACTORS WORKERS COMPENSATION APPLICATION
Complete form and Submit online or Download the Adobe Acrobat version and fax to 206.378.1136
Applicant's Name:
Federal Employer ID#:
Applicant's Mailing Address:
Years in Business:
Location of Applicant's Business Operations:
Years at this Location:
Applicant Conducts Business As: An Individual An Corporation A Partnership
Proposed Effective Date:
Proposed Expiration Date:
COMPLETE NAME AND TELEPHONE NUMBER OF THE PERSON TO CONTACT:
Inspection Contact:
Telephone Number:
Premium Audit Contact:
Telephone Number:
RATING INFORMATION:
 
No. Of Employees
Estimated Annual Payroll
Single Family Construction
(under 3 story)
Class Code#5651
#
$
Roofing all Types
Class Code#5551
#
$
Clerical
Class Code#8810
#
$
Other
#
$
 
Name:

Copyright © 2011 BIM Inc. All rights reserved.