Workers' Compensation - Applications & Forms
Submission Requirements

We will require a complete submission to determine if we have a potential worker’s compensation market for the risk.  Below is a checklist to ensure you have included all required documentation:

  • ACORD 130 WC Application
  • Detailed Description of Operations
  • Supplemental Application  (may be required based on industry and/or premium size)
  • Current Experience Modification Worksheet, if applicable/available
  • 3-4 Years currently valued loss runs within 90 days of effective date


Email submissions to:

CA & Western States (AK, AZ, CO, HI, ID, MT, NM, NV, OR & UT): workcompsf@5starsp.com

All Other States: workcomp@5starsp.com

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