Workers Compensation Application
Workers Compensation Application

Section 1 of 2 - General Business Info

if different from mailing
MM slash DD slash YYYY

Section 2 of 2 - Workers Compensation

Include in coverage?(Required)
Include in coverage?
Is a written safety program in operation?(Required)
Do you use subcontractors?(Required)
Have there been any losses, claims or suits against you in the past 5 years?(Required)
This field is for validation purposes and should be left unchanged.

Let us help you shield your business!

ksturgill@hakorisk.com
Need A Bond Now? Click Here

Thank you for choosing Hako Risk & Insurance as your local commercial insurance provider.  We are here to serve you and your insurance needs. If you have any questions, please do not hesitate to contact us.

Proudly serving Arizona, Colorado, Oregon, Washington, Idaho, Montana, Nevada, Utah, California, Wyoming, Texas, New Mexico

Choose Us as Your Insurance & Risk Management Partner
  •   Phoenix Arizona
  •   San Francisco California
  •   Montrose Colorado
  •   Kalispell Montana
  •   Portland Oregon

Main: (844) 850-4400

Customer Service:  customerservice@hakorisk.com
Certificates and Policy Changes: supportservice@hakorisk.com

© 2007-2022, Doing business in California as Hako Risk & Insurance Services (License # 6006242).
All rights Reserved

Thank you for choosing Hako Risk & Insurance

________________________________

AK  AL  AR  AZ  CA  CO  CT  DC  DE  FL  GA  HI  IA  ID  IL  IN  KS  KY  LA  MA  MD  ME  MI  MN  MO  MS 
MT  NC  ND  NE  NH  NJ  NM  NV  NY  OH  OK  OR  PA  RI  SC  SD  TN  TX  UT  VA  VT  WA  WI  WV  WY