WC FORM 9 Rev. 4-2003
NOTICE OF CANCELLATION TO THE DEPARTMENT OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION DIVISION 649 MONROE STREET SUITE 3816 MONTGOMERY, AL 36131 STATE UNEMPLOYMENT COMPENSATION TAX NUMBER_________________________ FEDERAL ID NUMBER_________________________________________________________ CORPORATION/LLC___________________________________________________________ DOING BUSINESS AS__________________________________________________________ ADDRESS_____________________________________________________________________ ADDITIONAL LOCATIONS COVERED____________________________________________ ______________________________________________________________________________ NATURE OF BUSINESS_____________________________NAICS______________________ DATE OF CANCELLATION__________________________REASON____________________ POLICY NUMBER______________________________________________________________ INSURANCE CARRIER__________________________________________________________ NCCI CODE___________________________________________________________________