Nicholas Hill Group

Are your activities limited to sales and distribution (not a manufacturer)? *

Yes

No (we manufacture products or do other things)

Primary contact name *

First Name

Last Name

Phone *

(###)

###

####

Business address or primary location *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Any other location(s) address (if applicable)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date business was established *

MM

DD

YYYY

Are you currently insured for workers compensation *

Yes

No

Are any employees leased from a PEO organization *

Yes

No

Do you want to include owners/officers *

Yes

No

Does your company qualify for experience MOD (if applicable) *

Yes

No

I don't know

N/A

Any losses in the past 5 years *

Yes

No

If you have had a WC loss (claim) in the past, do you have your loss history *

If yes, please email your loss history to [email protected]

Yes

No

Does your company have a safety program that you adhere to *

Yes

No