Service Company Application {WC 2007}

SERVICE COMPANY APPLICATION. This is is a confidential form required under the Louisiana Workers’ Compensation Act for service companies that wish to operate under the state’s workers’ compensation program. The form, filed with the Louisiana Office of Workers’ Compensation Administration, collects identifying information including the company’s legal name, business structure (corporation, partnership, or individual), addresses of both the home and Louisiana offices, and names of owners, partners, or corporate officers. Applicants must also provide the name and address of their resident claims agent and submit personnel summaries and resumes in compliance with LAC Title 40, Section 1715(c). The application must be notarized, certifying that all information provided is true and current. www.FormsWorkflow.com