Forms
Download the workers’ compensation forms you’ll need to complete your application.
Required for all industries
Loss History Affidavit
Fill out the top and sign the bottom of this form. It states whether your company has had a workers’ compensation claim in the past three years. If you have carried workers’ compensation in the past three years, we’ll also need the history of those claims (your “loss runs”). Don’t have them on hand? You can request your loss runs from an adjuster at your carrier — they can usually send them over within hours.
Download Loss History Affidavit PDFRequired for staffing agencies
Staffing Supplemental
As carriers have taken a firmer stance with staffing companies, they now require additional detail about your business. Please answer every field, and be as accurate as possible.
Download Staffing Supplemental PDFClient List
Because workers’ compensation pricing is state-based, the carrier needs to know which states your staffing company operates in. Please list at least one end client in every state you’d like a quote for. In the spreadsheet, also note what you pay your employees weekly and the job duties they perform on-site (for example: servers, pick/pack/ship, long-term nursing). Please note: no one will contact any end client you list in any way — this is only to satisfy the underwriter’s requirements.
Download Client List XLSXQuestions about any of these forms? Call us at 833-325-8352 or email info@bluejaybrokers.com.