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Workers Compensation

Workers Compensation Form

Public Risk Insurors is a leader in providing workers compensation insurance coverage for public entities across the state. If you would like Public Risk Insurors to provide a quotation for your public entity, please provide the following information.

You may complete the application online and then click “submit” or you may print these pages and return them to us via fax (615-369-0647) or via email to laura@publicriskinsurors.com.

Thank you for choosing Public Risk Insurors! We look forward to serving you!

 

Public Entity Information
Public Entity Information
Contact Person (Inspection)
Inspection
Contact Person (Accounting)
Accounting
Contact Person (Claims Info)
Claims Info
Submission Request

Status of Submission




Billing / Audit Information

Billing / Audit Information



Policy Information

Part 2 - Employer's Liability (1M, 500K, or 250K)

Part 3 - Other States Ins

Rating Worksheet

Rating Worksheet


 


 


 


 

Prior Carrier History / Loss Information (Please Provide a Minimum of 5 Years)
Prior Carrier History / Loss Information (Please Provide a Minimum of 5 Years)