Can this application be e-signed?

Yes; electronic signatures are enforceable under the federal ESIGN framework (15 U.S.C. ch. 96, 2000) and UETA in most states. Confirm state exceptions and insurer acceptance before relying on e-signatures for documents with statutory exceptions.

What happens if names or FEINs mismatch?

Name or FEIN mismatches can delay underwriting, trigger audits, or result in coverage disputes. Correct discrepancies with official documents and resubmit the application to avoid premium or claim complications.

Are loss runs mandatory?

Most carriers require loss runs for underwriting. Providing three to five years of claims detail improves pricing accuracy and speeds approval; missing loss runs typically prompt follow-up and underwriting holds.

When is notarization required?

Notarization requirements vary by state and insurer. Remote online notarization (RON) is permitted in most states but check the relevant state notary rules and the carrier's acceptance policy before using RON.

How should subcontractors be reported?

Disclose subcontractor usage and payments as instructed on the application. Failure to report subcontractor arrangements or to secure certificates of insurance can result in uncovered exposures and audit adjustments.

What records should I retain?

Retain the signed application, attachments, and audit trails for the policy term plus applicable retention periods (IRS, HIPAA, and state rules). Keep electronic copies with tamper-evident signatures and accessible audit logs.

Electronic Signature
Templates
Insurance
WC Insurance Application

WC Insurance Application

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Workers’ Compensation Insurance Application

Montana State Fund

855 Front Street, PO Box 4759, Helena, MT 59604-4759

Customer Service: (800) 332-6102 or (406) 495-5000 | Fax: (406) 495-5020

If you have questions, please refer to the application instructions.

Business Information - Mandatory

Applicant Name (Last name, First Name, Middle Initial)

Taxpayer Identification #

Mailing Address (Street or PO Box)

City, State & Zip Code

List All DBA’s (Doing Business As)

Phone Number

E-mail Address

Years in Business

Business Type

Individual Partnership Corporation Limited Liability Co-member-managed Limited Liability Co-manager-managed Non-Profit Corp Other (specify)

NCCI Risk ID Number (if known)

Locations - Mandatory

Street, City, County, State, Zip Code – Physical Location #1

Physical Location #2

Physical Location #3

Policy Information - Mandatory

Do you want a policy issued for coverage for your employees on the proposed effective date?

Yes No

Do you want a quote before deciding to issue a policy for your employees on the proposed effective date?

Yes No

If you choose “Yes” to this option you must notify Montana State Fund if you want a policy issued and the date you want the policy to be effective. A policy will not automatically be issued by Montana State Fund.

Proposed Effective Date

Proposed Expiration Date

Other States Locations (States)

Medical Deductible?

Yes No

Employer’s Liability Limits

$ Each Accident

$ Disease - Each Employee

$ Disease - Policy Limit

Rating Information - Mandatory

State	Loc	Class Code	Code Description	Description of Employee Duties	Full Time	Part Time	Estimated Annual Payroll

Ownership Information and Coverage Selection - Mandatory

Mandatory: List all names of owners, partners, LLC member/managers or managers, corporate officers or shareholders. Please specify if the individuals are to be included or excluded.

Are any of the persons related?

No Yes

If “Yes”, please explain below.

Names	Title	Ownership %	Duties Performed in MT	Included/Excluded	Class Code	Elective Coverage Amount

Prior Carrier Information and Loss History - Mandatory

Provide requested information for the past 3-5 years.

Year	Insurance Company & Policy Number	Annual Premium	Experience Mod	# Claims	Cancellation/Expiration Date	Reason for leaving company

Description of Business Operations - Mandatory

Please provide a description of the entire business operations and products.

General Information - Mandatory

Explain All “Yes” Responses

1. Does your business operate an aircraft for business purposes?	Y	N
2. Have past, present or discontinued operations involve(d) storing, heating, discharging, applying, disposing, or transporting of hazardous material?	Y	N
3. Any work performed underground or above 15 feet?	Y	N
4. Is business engaged in any other type of business or are you a subsidiary of another entity?	Y	N
5. Are subcontractors used?	Y	N
6. Any work sublet without certificates of insurance?	Y	N
7. Is a written safety program in operation?	Y	N
8. Any group transportation provided?	Y	N
9. Any employees under 16 or over 60 years of age?	Y	N
10. Any seasonal employees?	Y	N
11. Is there any volunteer or donated labor?	Y	N
12. Any employees with physical handicaps?	Y	N
13. Do employees travel out of state?	Y	N
14. Are athletic teams sponsored?	Y	N
15. Are physicals required after offers of employment are made?	Y	N
16. Any prior coverage declined/cancelled/non-renewed in last 3 years?	Y	N
17. Are employee health plans offered?	Y	N
18. Is there a labor interchange with any other business/subsidiary?	Y	N
19. Do you lease employees to or from other employers?	Y	N
20. Do any employees predominantly work at home?	Y	N

General Information - Mandatory (Continuation from page 2)

21. Any tax liens or bankruptcy within the last 5 years?	Y	N
22. Any undisputed and unpaid workers’ compensation premium due from you or any commonly managed or owned enterprises?	Y	N
23. Did you acquire this business from another owner?	Y	N
24. Are you related to the prior owner?	Y	N
25. Do you have workers’ compensation insurance in other states?	Y	N
26. Will you be hiring Montana residents?	Y	N

Memberships and Elective Coverages

Are you a member of the following?

NFIB - National Federation of Independent Businesses MBIA - Montana Building Industry Association MLA - Montana Logging Association MCM - Motor Carriers of Montana MSFAG - Montana State Fund Agriculture Group

One of the following:

Montana Stockgrowers Association Montana Organic Association Montana Wool Growers Association Montana Grain Growers Association Montana Farmers Union Montana Pork Producers Montana Farm Bureau Montana Cattlemen’s Association

Elective Coverages - please indicate if you need any of the following, subject to State Fund approval.

Sole Proprietor / Partner / LLC Member Manager Corporate Officer / LLC Manager Dependent family member or spouse Household or domestic employee Casual employment Person working in return for aid or sustenance only Volunteer worker (including volunteer firefighters and/or EMTs) Amateur athletic officials Real estate, securities or insurance salesperson Direct home seller of consumer products Newspaper carrier / Freelance correspondent Contract, licensed barber or cosmetologist Petroleum land professional Licensed jockey, trainer, ass’t trainer, exercise or pony person Non-Montana resident employees Officers or managers of ditch companies or water users companies Minister or member of a religious order Persons providing companionship or respite care Professional athletes engaged in contact sports Motor carrier hired by a freight broker or freight forwarder A musician performing under a written contract

Do you require certificates of Insurance? List names and address for required certificate holders below.

Do you want an accountant/CPA to receive all correspondence regarding your policy? List their name and address below.

Explain all “Yes” responses (reference item #). If additional space is required, use another page and attach to this application.

An incomplete or unsigned application may cause delays in coverage.

Please complete the entire application, sign it and return the original to Montana State Fund, PO Box 4759, Helena, MT 59604-4759

If you have questions, please call a Customer Service Specialist at (800) 332-6102.

Certification - Mandatory

I herby certify that I have read and fully understand the accompanying instructions and have completed this application form to the best of my ability. All the information provided herein is true and correct.

Authorized Signature

Title

Date

Phone Number

What a WC Insurance Application Is and why it matters

A WC Insurance Application is the formal form employers submit to request workers' compensation coverage from an insurer. It collects employer identification, payroll by classification, claims and loss-run history, ownership and trade descriptions, desired coverage limits, and signature authority. Insurers use the application to underwrite risk, set premiums, and schedule audits; state regulators review applications to confirm statutory coverage. Electronic submission and e-signatures are generally accepted under U.S. law when statutory exceptions do not apply.

Why completing the application carefully reduces risk

A complete, accurate WC Insurance Application helps ensure appropriate coverage, reduces underwriting delays, minimizes premium misclassification, and creates a clear record for audits and claims. Accurate loss runs and payroll detail directly affect premium and claim handling outcomes.

Typical parties who complete or manage the application

Knowing each party's responsibilities reduces omissions, speeds underwriting, and establishes clear points of contact for post-issuance audits.

Employers (owners, HR): Provide payroll, job classifications, and claim history to obtain coverage and set premiums.
Brokers and agents: Assemble loss runs, complete underwriting questions, and submit the application on the employer's behalf.
Risk managers and payroll teams: Verify classification codes, ensure accurate payroll allocation, and retain documentation for audits.

Core sections to include in a professional WC Insurance Application

A compliant application groups employer identity, payroll and classifications, claims history, coverage selections, endorsements, and signature authority. Each section should be complete, consistent, and supported with attachments where required.

Employer Identity

Legal business name, DBA, FEIN, physical address, mailing address, and contact information; matches tax and licensing records to avoid underwriting delays.

Payroll and Class Codes

Break out payroll by classification code and by state; include projected payroll for the policy period and actual payroll for past policies to support premium calculations.

Loss History

Attach three to five years of loss runs and describe open claims, reserves, and trends; insurers use this to calculate experience modification and underwriting decisions.

Coverage and Limits

Specify desired policy limits, deductible options, and any stop-loss or employers' liability limits; note state-mandated minimums where applicable.

Payroll Practices

Disclose subcontractor usage, leased employees, and any independent contractor arrangements that affect exposure and classification.

Signature and Authorization

Identify authorized signers, corporate titles, and dates; indicate whether electronic signatures are accepted and include any required attestations.

Key information fields required on a WC Insurance Application

Employer Name: Full legal name

Tax ID / FEIN: Nine-digit FEIN

Payroll Breakdown: Payroll by class

Loss Runs Attached: PDF or printed

Authorized Signer: Name and title

Effective Date: MM/DD/YYYY

Step-by-step: completing and submitting the application

Follow these steps in order to reduce omissions and speed insurer review. Gather attachments and confirm authorized signers before submission.

01

Gather Documents: Collect loss runs, payroll reports, and FEIN verification documents.
02

Complete Fields: Enter employer details, payroll by class, and coverage choices accurately.
03

Attach Evidence: Upload loss runs, certificates, and signed authorization documents.
04

Submit and Track: Send to insurer or broker and retain submission confirmation.

Configuring an online completion workflow for the application

Set up required fields, signer order, and authentication before sending. Use conditional visibility for payroll or subcontractor sections.

Field	Configuration
Authentication	Email link or SMS code
Signature Type	Drawn, typed, or image
Conditional Logic	Show payroll fields when applicable
Attachments	PDF loss runs required

Where to send the completed application and supporting files

Applications are typically submitted to the broker or directly to the insurer's underwriting portal. Keep a signed copy for your records.

To Broker: Email or upload to the broker portal for review.
To Insurer: Submit through insurer online portal or agent submission channel.
To State Agent: If required, file supplementary forms with the state regulator.
Retain Copy: Keep a signed PDF for audits and claims.

Digital signing and file format considerations

Ensure the chosen solution can produce a tamper-evident signed PDF with an audit trail and easily exportable attachments for insurer review.

File Formats: PDF, DOCX supported
Integrations: Salesforce, NetSuite, Google Workspace
Authentication: Email, SMS, or advanced methods

Key timelines and typical processing expectations

Timelines vary by insurer and state. The items below reflect common expectations; confirm specific deadlines with the issuing carrier or broker.

Policy Effective Date:

Coverage begins on the insurer-issued effective date.

Premium Audit Window:

Audits commonly occur within 12 months of policy inception.

Claims Reporting:

Report workplace injuries to insurer as soon as possible.

Loss Run Submission:

Provide at least three years of loss history.

Cancellation Notices:

Insurer notices follow state-mandated timelines.

Common penalties and risks from incorrect applications

Coverage Denial: Incomplete info may void coverage

Premium Adjustment: Misclassification leads to audit surcharges

Regulatory Fines: State regulators may assess penalties

Claim Delays: Missing data slows claim handling

Increased Premiums: Undisclosed exposures raise rates

Legal Exposure: Fraud or misstatement risks penalties

How eSignature vendor pricing and features compare for completing WC applications

Select a provider that supports secure e-signing, audit trails, and required authentication. Below is a high-level pricing and capability snapshot; compare plan details for exact features.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 env/user/yr	Varies	Varies	Varies

Practical tips to complete the application accurately and efficiently

Adopt quality-control steps and consistent recordkeeping to reduce audits and accelerate underwriting decisions.

Verify names and tax IDs

Cross-check employer legal name and FEIN against tax filings and state registration before submission. Inconsistent identifiers commonly delay underwriting and complicate claims handling, so resolve discrepancies in advance.

Provide clear payroll breakdowns

Allocate payroll by state and by precise classification code. Rounded or aggregated payroll figures can trigger premium audits and reclassification, increasing retroactive charges and administrative burden.

Attach complete loss runs

Include loss runs showing reserves and payments for the last three to five years. Partial loss histories prompt carrier follow-up and can negatively affect underwriting decisions and pricing.

Document authorized signers

Maintain a record of individuals authorized to sign on behalf of the entity. Failure to provide proper authorization can render the application incomplete or lead to disputed claims.

Frequently asked questions about WC Insurance Applications

Answers to common concerns about e-signatures, required attachments, and handling discrepancies when preparing the application.

Need help? Contact support

Can this application be e-signed?
Yes; electronic signatures are enforceable under the federal ESIGN framework (15 U.S.C. ch. 96, 2000) and UETA in most states. Confirm state exceptions and insurer acceptance before relying on e-signatures for documents with statutory exceptions.
What happens if names or FEINs mismatch?
Name or FEIN mismatches can delay underwriting, trigger audits, or result in coverage disputes. Correct discrepancies with official documents and resubmit the application to avoid premium or claim complications.
Are loss runs mandatory?
Most carriers require loss runs for underwriting. Providing three to five years of claims detail improves pricing accuracy and speeds approval; missing loss runs typically prompt follow-up and underwriting holds.
When is notarization required?
Notarization requirements vary by state and insurer. Remote online notarization (RON) is permitted in most states but check the relevant state notary rules and the carrier's acceptance policy before using RON.
How should subcontractors be reported?
Disclose subcontractor usage and payments as instructed on the application. Failure to report subcontractor arrangements or to secure certificates of insurance can result in uncovered exposures and audit adjustments.
What records should I retain?
Retain the signed application, attachments, and audit trails for the policy term plus applicable retention periods (IRS, HIPAA, and state rules). Keep electronic copies with tamper-evident signatures and accessible audit logs.

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