PEST CONTROL WORKERS COMPENSATION APPLICATION
Complete form and Submit online or Download the Adobe Acrobat version and fax to 206.378.1136
Applicant's Name:
Federal Employer ID#:
Applicant's Mailing Address:
Years in Business:
Location of Applicant's Business Operations:
Years at this Location:
Applicant Conducts Business As: An Individual An Corporation A Partnership
Proposed Effective Date:
Proposed Expiration Date:
COMPLETE NAME AND TELEPHONE NUMBER OF THE PERSON TO CONTACT:
Inspection Contact:
Telephone Number:
Premium Audit Contact:
Telephone Number:
RATING INFORMATION:
 
No. Of Employees
Estimated Annual Payroll
Pest Control
Class Code#9031
Termite
Class Code#5650
Clerical
Class Code#8810
Other
 
Name:

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