Ghost Workers Comp - Republix Risk Mitigation Insurance Solutions

Ghost Workers Comp Form

"*" indicates required fields

Business Details

Name of Person Completing Form:*

First Last

Phone Number:*

Email:*

Business Name:*

Business Entity:*

FEIN / Tax-ID Number:

Mailing Address:*

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?*

Yes

Physical Address:*

Street Address City State ZIP Code

Company Website:

Effective Date

Are You A Contractor?*

Yes

Brief Description of Operations:*

Year Business Started:

Number of Employees:

Estimated Annual Employee Payroll:

Estimated Annual Revenue:

Owners*

Name

% Ownership

Additional Contractor Details

Contractors 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?

Consent*

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.