Workers' Compensation Insurance Verification



Insurance Verification Request

Fields marked by * are required and cannot be left blank.

If you need assistance in identifying an employer's workers' compensation insurer, please complete the required information.
The completed form will be directed to the Insurance Verification Staff for review.
Name*
Date
Address*
City*
State*
Zip Code*
Telephone
Email*
Fax
 
Employer name*
D/B/A
Employer address
City*
State
Zip Code
Employee name
Employee address
City
State
Zip Code
 
Date of Interest: Prior to 1985
Start Date (mm/dd/yyyy)
End Date (mm/dd/yyyy)
Date of Interest: 1985 to Current
Start Date (mm/dd/yyyy)
End Date (mm/dd/yyyy)
Comments