WC Approval Request

WORKER'S COMPENSATION APPROVAL REQUEST
Recruiting Firm Name *
Recruiter Name *
Recruiter E-mail *
Physical Work Location (i.e. office, hospital, warehouse, outpatient facility, nursing home) *
Does this job description involve driving in a vehicle?

YES NO
Job Title *
Pay Rate (must be an exact dollar amount) *
Estimated hours per week *
Estimated length of assignment *
State *
Client company name that the contractor will be working for *
Client company address that the contractor will be working *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Brief Description of Client Operations *
ex. Software Development Company
Select from the below two choices to submit the job description
Upload Job Description File
Paste Job Description Link
Additional Notes
* Please allow up to 72 hours to receive your approval.
Enter the message as it's shown *
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