Common Contracts

Kahnawà:ke Worker's Compensation MSI A Application Agreement Form

Worker's Compensation Agreement • March 12th, 2013

• Contract Type
  Worker's Compensation Agreement
• Filed
  March 12th, 2013

Company/Organization Name: Company/Organization Owner Name: Extension: Company/Organization Owner E-mail Address: Company/Organization Address: Company/Organization Telephone Number: Company/Organization Fax Number: Finance Contact Name: Extension: Finance Contact E-mail Address: Finance Contact Telephone Number: Human Resource Contact Name: Extension: Human Resource Contact E-mail Address: Human Resource Contact Telephone Number: Mode Of Payment: 🞎 Monthly 🞎 Bi-Yearly 🞎 Yearly 🞎 Duration Of Project: (Start Date - End Date) 🞎 Seasonal: ( Date of Operation: From - To) *For Duration of Project or Seasonal; If you exceed the end date written above you must inform Mohawk Self Insurance. In the event you do not inform Mohawk Self Insurance and an injury occurs the claim will be denied. Does your Company/Organization Safety Program: 🞎 Yes 🞎 No * Must Provide Mohawk Self Insurance with a copy of your Company/Organization's Safety Program. For