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Check boxes: Please check “Self-Insured Section.”
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From: Policy Number: Please enter your BWC policy number.
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Entity: Enter your company’s name as it appears on the articles of incorporation.
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DBA (doing business as): Enter your company’s DBA, if any.
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Address: Please list your company’s address including street, P. O. Box, city, state and nine digit zip code.
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Date (line): Enter the date that the agreement is to take effect.
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Representative’s name and address: On this line enter the company name of the authorized representative along with their street, P. O. Box, city state and nine digit zip code.
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Signature: A person authorized to sign for your company should sign the form.
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Title: Enter the title of the person signing the form.
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Date: Enter the date that the form was signed.
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