Workers' Compensation Supplemental Application

Complete the following information to receive a quote from NWPA NTMA Group Worker's Compensation Plan.

Exposure Information - Complete information for any Class represented in the business.

Loss History - Please provide a description of workers' compensation claims over the past 5 years (if claims have occurred, provide currently valued loss runs).

  Day Shift/ Office Hours
  Second Shift
  Third Shift
  Yes
  No
  Yes
  No
  Yes
  No
  Yes
  No
  Yes
  No
  Yes
  No
  Yes
  No
  Yes
  No
  Yes
  No

  Yes
  No
  Medical Panel
  Modified Duty
  Safety Incemtive Program
  Post Offer Drug Screening
  Post Accident Drug Screening