(Employer Must Complete)
(Employee must complete, but Employer may transcribe)
(If applicable, Witnesses must complete)
(If applicable, Employee must complete)
Master Policy Numbers
Business Insurers of Georgia SUNZ – WC014-00001-021
InSource United Wisconsin Insurance Company (UWIC) – WC526-00001-021-SZ
If you do business in one or more Multiple Coordinated Policy (MCP) states, a unique policy number for each MCP state will be assigned to you.
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General Forms – All Clients
Business Insurers of Georgia SUNZ
InSource United Wisconsin Insurance Company (UWIC)
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