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Workers Compensation
Firstname *
Lastname *
Workers Compensation laws are designed to ensure that employees who are injured or disabled on the job are provided with fixed monetary awards, eliminating the need for litigation. These laws also provide benefits for dependents of those workers who are killed because of work-related accidents or illnesses.

The Federal Employment Compensation Act provides workers' compensation for non-military federal employees. Many of its provisions are typical of most worker compensation laws. Awards are limited to "disability or death" sustained while in the performance of the employee's duties but not caused willfully by the employee or by intoxication. The act covers medical expenses due to the disability and may require the employee to undergo job retraining. A disabled employee receives two thirds of his normal monthly salary during his disability and may receive more for permanent physical injuries, or if he has dependents. The act provides for compensation for the survivors of an employee who is killed. The act is administered by the Office of Workers Compensation Programs.

Policyholder Name
Occupation
Current Employer
Street Address
City *
State *
ZIP Code *
E-Mail *
Phone *
Fax

# Employee Groups *
# Losses-Claims In Past 5 Years *
Nature Of Business *
Total Annual Gross Receipts *
$
# Of Owners *
Payroll Of Owners *
$
# Of Employees *
Payroll Of Employees *
$
24 Hour Company *
YesNo
Deep Frying Of Food *
YesNo
Filling Of Propane Tanks *
YesNo
Currently Insured *
YesNo

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