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Code Request Form

Worker’s Compensation Code Addition Request

Client Name:

Request Date:

Requested By:

WC Information

WC Code Requested (If Known):

WC State:

Effective Date

Number of Employees Working Under Requested Code:

Combined Gross Annual Payroll:

Physical Location Where Duties Will be Performed:

Street Address:

City:

State:

Zip:

Detailed description of Job Duties to be Performed Under this Code:

x

x