HROI : Workers' Comp Cert Request

Get a Quote Must have over 5 employees.
Contact Name:
Company Name:
# of W-2 Employees:	State:
Phone #
E-mail:

Workers' Comp

Questions or need help?
Email wc@hroi.com

Workers' Compensation Certificate of Insurance

An additional $500 fee in advance is required for waiver of subrogation
Note: "Additional Insured" only applies to general liability insurance certificates, not workers' compensation certificates

Submitted By:

Your Company Name (as identified with HR Outsourcing)

Your Address:

Your Phone Number:

Please note that certificates can take up to 48 hours to produce.

Distribution:

A copy should be emailed in PDF to:
Email:

Email:

Email:

A copy should be faxed to:

Attention:	Fax #:

Certificate Holder Name and Address:

Special Instructions: