PROSPECTIVE WORKERS' COMPENSATION POLICYHOLDER INFORMATION FORM

Company Contact

Company Name

Phone Number

Physical Address

City

State

Zip Code

County or Parish

Line of Business

Annual Payroll

Number of Employees

Is this a start-up business?

Yes No

CURENT WORKERS' COMP INFORMATION

Agency

Carrier

Expiration Date

Please note any special circumstances or information that would be helpful to AMERISAFE below: