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Workers' Compensation History

Contractor License #	557066
Contractor Name	FORM INC

Workers' Compensation History

Insurance Company FALLS LAKE FIRE AND CASUALTY COMPANY Policy # FLA015734 Effective Date 11/07/2020 Expiration Date 11/07/2021

Insurance Company ACCREDITED SURETY AND CASUALTY COMPANY INC Policy # 1ATCA16002577 Effective Date 11/07/2019 Expiration Date 11/07/2020

Insurance Company STATE COMPENSATION INSURANCE FUND Policy # 9105186 Effective Date 07/03/2015 Cancellation Date 11/07/2019

Insurance Company STATE COMPENSATION INSURANCE FUND Policy # 9105186 Effective Date 07/02/2014 Expiration Date 07/02/2015

Insurance Company STATE COMPENSATION INSURANCE FUND Policy # 1588008 Effective Date 05/15/2001 Expiration Date 05/15/2014

Insurance Company STATE COMPENSATION INSURANCE FUND Policy # 1574008 Effective Date 05/15/2000 Expiration Date 05/15/2001

Insurance Company ALLIED WORLD INSURANCE COMPANY Policy # FW99980119 Effective Date 05/15/1999 Expiration Date 05/15/2000

Insurance Company CLARENDON NATIONAL INSURANCE COMPANY Policy # 01KM00026828 Effective Date 05/15/1998 Expiration Date 05/15/1999

Insurance Company EXEMPT Policy # Effective Date 08/04/1997 Expiration Date

Insurance Company CALIFORNIA COMPENSATION INSURANCE COMPANY Policy # G976141623 Effective Date 06/10/1997 Expiration Date 06/10/1998