Nonelection of Workers' Compensation or Employers' Liability Coverage
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This page shows analysis of submitted data, such as the number of submissions per component value, calculations, and averages. Additional components may be added under the "Add analysis components" fieldset.
Name of Employer:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 3.11 |
Date:
| Left Blank | 0 |
| User entered value | 1522 |
Full Name of Individual:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 2.39 |
Email:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 3.17 |
City of Residence:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 1.41 |
County of Residence:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 1.10 |
State of Residence:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 1.14 |
Full Name of Witness 1:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 2.18 |
Full Name of Witness 2:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 2.17 |
Signing Indication:
| Signed | 1522 |
Check either alternative (1) or (2):
| (1) The employer does not elect the employers’ liability coverage. | 1443 |
| (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. | 79 |
Full Name of Authorized Agent:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 2.40 |
Email of Authorized Agent:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 3.18 |
Relationship to Employer of Authorized Agent:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 1.26 |
City of Residence:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 1.40 |
County of Residence:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 1.10 |
State of Residence:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 1.13 |
Full Name of Witness No. 1:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 2.18 |
Full Name of Witness No. 2:
| Left Blank | 0 |
| User entered value | 1522 |
| Average submission length in words (ex blanks) | 2.17 |
Signing Indication:
| Signed | 1522 |