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___________________________________________________________________