When this form may help
Use this form to organize payroll, employee duties, class information, operations, safety practices, prior coverage, and loss experience. Confirm state and class details before submission.
Authority boundary: This Hedge form is a submission-preparation resource. It is not a quote, binder, coverage commitment, market-access statement, or instruction to release a risk to a carrier.
Topics covered
- payroll
- employee duties
- class codes
- safety
- loss experience
Before you send it
Complete the form with current facts from the insured. Confirm the named insured, operations, locations, requested coverage, effective date, and loss information. Include the primary application, loss runs, schedules, and other documents that apply to the account. Hedge will identify any additional market-specific requirements after review.
Download the fillable PDF
This file is published by Hedge and can be completed in a PDF editor. Review every answer before attaching it to a submission.
Download Hedge Workers Compensation Supplemental