Workers Compensation Form
Please fill out the form below and we will be in touch with you.

Hotel Name :
Corporate or Legal Name:
Hotel Address:
Contact Name:
Contact Phone Number:
Contact Title:
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Best Time To Reach You:

The following information can be found on your existing policy. The class code will be a four digit code with the corresponding payroll next to it and the experience mod is usually listed below the class codes.

Experience Mod:
Class Code (1):
Payroll (exposure):
Class Code (2):
Payroll (exposure):
Class Code (3):
Payroll (exposure):