Workers' Compensation Supplemental Application

Step 1 of 5

Contact Name and Phone Number

Prior Payroll and Premium Information

TOTAL ANNUAL PAYROLL
TOTAL ANNUAL PAYROLL
TOTAL ANNUAL PAYROLL

Customer Profile

Business Entity
FOR CORPORATIONS, PLEASE IDENTIFY THE FOLLOWING OFFICER AND OWNERSHIP INFORMATION: (Note that ownership must total 100%)
For sole proprietors, are any relatives who reside in your household employed in the business?
Are you involved in “Wrap Up” or “OCIP” projects?
If yes, is the coverage for the wrap up provided by another contractor or are you providing the coverage for the project?

About the LCIS Workers' Compensation Supplemental Application Form

In order to keep your Workers' Comp records up to date, please complete the form on this page.

To make this process as convenient for you as possible, we are providing a number of options to provide us with this form.

How to Request a Certificate

There are a number of ways you can submit your request:

Online: Complete the form on this page and click the submit button.

Fax or Mail: If you prefer to fax or mail us the form, click the PDF icon below and a form will download for you to complete.

 

 

 

You can enter your information into the form, after which we suggest you save the completed form for safekeeping. You can then print it and either fax it to (559) 650-3558

OR

Mail the completed form to Workers' Compensation Department
Landscape Contractors Insurance Services, Inc.
1835 N. Fine Ave
Fresno CA 93727

Questions or concerns?
Call us at (800) 628-8735 or send us an email

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Landscape Contractors Insurance Services, Inc.
1835 N. Fine Ave, Fresno CA 93727
Tel (800) 628-8735 Fax (559) 650-3558
CA LIC # 0755906

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