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Workers' Compensation -
Western Region/CA




Tools And Applications

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Workers Compensation - Western Region/CA


Submission Requirements
Submission Checklist

Fillable ACORD® Forms Library & Samples
State Specific ACORD® Forms - Workers Compensation Series
ACORD® 25 - Certificate of Liability Insurance
ACORD® 35 - Cancellation Request/Policy Release
ACORD® 125 - Commercial Insurance Application
ACORD® 130 - Workers Compensation Application

Applications
Broker of Record Letter – WC – Quote Only
Confidential Request For Ownership Information - Form (ERM-14)
Confidential Request For Ownership Information - Instructions
IRS Form W-9 (Request For Taxpayer ID No. and Certificate)
Loss Run Request
Nursing Home Application
Questionnaire - Auto Dismantlers
Questionnaire – Health care Services
Questionnaire – New Venture
Questionnaire – Tow Trucks
Supplemental Trucking Application
Supplemental Workers' Compensation Application
Waiver of Subrogation Worksheet - Specified Basis





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