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If we determine the worker to be an employee, we will charge a premium based on their compensation. This form is required to be completed at the time of hire and a new form must be completed at the beginning of each year coverage is written with KEMI. Name DBA Business Address Is this also your home address? City State Business Phone I operate as a(n) I have do not have Mobile Phone Partnership (Per KRS 342.012 a FEIN is required) Social Security Number (SSN) No Zip Home Phone Ind.

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