Workmen Compensation Application


Applicant Name
First Name
Middle Name
Last Name
Complete Address
Occupation
Risk Situation
Nature of business covered
Employees
Number of Employees
Salaries
Foremen
Number of Foremen
Wages
Workers
Number of Workers
Wages
Is the job based on instruments or machinery?
Please, state
Is the job based on manual work?
Give details of Accidents occured in your establishment during the past three years
Estimated annual wages
Plot Number
Region
Number of under ground floor(s)
Number of upper floor(s)
Total Area (in m2)
Cost per m2
Total Wages