Free WC Notice of Coverage - Alabama


File Size: 5.8 kB
Pages: 1
Date: June 22, 2004
File Format: PDF
State: Alabama
Category: Workers Compensation
Word Count: 57 Words, 1,067 Characters
Page Size: Letter (8 1/2" x 11")
URL

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

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WC FORM 8 Rev 6/2004

NOTICE OF COVERAGE TO THE DEPARTMENT OF INDUSTRIAL RELATION 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____________________ EFFECTIVE DATE OF POLICY__________________EXPIRATION DATE__________________ POLICY NUMBER______________________________________________________________ INSURANCE CARRIER_________________________________________________________ NCCI CODE___________________________________________________________________