Ghost Workers Comp Form "*" indicates required fields Business DetailsName of Person Completing Form:* First Last Phone Number:*Email:* Business Name:* Business Entity:*Sole PropLLCCorporationFEIN / Tax-ID Number: Mailing Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is Physical Address Same As Mailing Address?* Yes No Physical Address:* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company Website: Effective Date MM slash DD slash YYYY Are You A Contractor?* Yes No Brief Description of Operations:*Year Business Started: Number of Employees:Estimated Annual Employee Payroll:Estimated Annual Revenue:Owners*Name% Ownership Add RemoveAdditional Contractor DetailsContractors License #* % of work Subcontracted out % of Residential Work % of Commercial Work % of Remodel/Install work % of New Construction Work % of Service/Maintenance Work Do you perform Government/Municipality Work?YesNoConsent* I agree to the Republix privacy policy and provide my consent to be contacted.I agree to the Republix privacy policy https://www.joinrepublix.com/privacy-policy-3/ and provide consent to be contacted via email, phone call and SMS text message regarding my insurance.