Workers Compensation Form – BC Commercial Insurance Services

You can fill out the form online, or download it.

You can download the form by clicking here. Make sure to either print it and fax it in, or save it and email it in.

Download it HERE

General Information
Named Insured
Prefix First Last Suffix
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Fax Number
Email
Years In Business
Number of Employees
FEIN #
Federal Employer Identification Number
Incorporated?

Locations

Class Code	Description	FT emp	PT emp	Annual Payroll

You can add more locations by clicking the "+" symbol.

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