Free WC Notice of Cancellation (Form WC ) - Alabama


File Size: 403.4 kB
Pages: 13
Date: December 21, 2006
File Format: PDF
State: Alabama
Category: Workers Compensation
Word Count: 55 Words, 1,070 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dir.alabama.gov/docs/forms/wc_notice_of_cancellation.pdf

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WC FORM 9 Rev. 4-2003

NOTICE OF CANCELLATION TO THE DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION DIVISION 649 MONROE STREET SUITE 3816 MONTGOMERY, AL 36131 STATE UNEMPLOYMENT COMPENSATION TAX NUMBER_________________________ FEDERAL ID NUMBER_________________________________________________________ CORPORATION/LLC___________________________________________________________ DOING BUSINESS AS__________________________________________________________ ADDRESS_____________________________________________________________________ ADDITIONAL LOCATIONS COVERED____________________________________________ ______________________________________________________________________________ NATURE OF BUSINESS_____________________________NAICS______________________ DATE OF CANCELLATION__________________________REASON____________________ POLICY NUMBER______________________________________________________________ INSURANCE CARRIER__________________________________________________________ NCCI CODE___________________________________________________________________