Copy of current policy declaration page – Showing Class Codes and Payroll
5 Year Loss Runs (Please sign attached Loss Run Request – Please photo-copy onto your store\Company Letterhead)
Signed NCCI Experience Modification Sheet (attached – Please photo-copy onto your store\Company Letterhead)
Owners/Officer Worksheet (attached)
Your business FEIN for entity to be covered and reported for proof of coverage.
Please contact either Sean McCutcheon or Kevin McCutcheon for a MFDA Workers Compensation Proposal:
McKee Anderson MFDA President for any questions