Workers’ Compensation Insurance Renewal Form
Business Information
Business Name
Contact Person
Business Address
Phone Number
Email
Policy Details
Policy Number
Current Policy Expiration Date
Number of Employees
Estimated Annual Payroll
Any Changes Since Last Policy Period?
No
Yes
If Yes, Please Explain
Claims Information
Any Workers’ Comp Claims in the Past Year?
No
Yes
If Yes, Please Provide Details
Additional Comments
Comments or Requests