Workers Compensation

Kelly & Co., Inc.

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PERSONAL INFORMATION

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Last Name:

Company Name:

Street Address

City

State

Michigan

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Fax Number

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CURRENT INSURANCE INFORMATION

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Insurance Carrier Name

Number of Years:

Type of Business:

Business Classification

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Claim History in Last 5 Years (Include all claims)

REQUESTED COVERAGES

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Payroll Class #1:

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Payroll Class #2: (if none leave blank)

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..............	Kelly & Co., Inc 2575 S Van Dyke Rd, Suite 102 Marlette, MI 48453	Marlette: 800.257.3735 989.635.2649 Fax: 989.635.3744	Kingston: 888.843.3388 989.683.2419 Fax: 989.683.3107	Kelly & Co., Inc 5951 State Street, Kingston, MI 48741