Please use the form below to describe your general business and any other information you may want to include and our representative will contact you. A red asterisk * beside a text box name indicates required information.

Date(mm/dd/yy) *Company Name

State ID# Federal ID#

*Address Line 1

Address Line 2

*City *State *Zip

*Phone(include area code) *Fax

*Email Address *Contact Name

1. Currently Using a Payroll Service: (Please Check)    Yes      No 

Which one? Annual cost?

2. When are Pay Periods: (Check One): Weekly-(52) Bi-weekly-(26)
Semi-monthly-(24) Monthly-(12)

3. Number of Employees: Full Time:     Part Time:     Total:

4. Workers’ Compensation  EX-MOD Factor:     Renewal Date:

CODES              RATES                   PAYROLL            CODES               RATES                   PAYROLL

      $           $

      $           $

 5. Total Gross Payroll: $ Current Premium: $

 Are These Workers Comp. Payroll Figures(Check One):  

Monthly    Quarterly       Annual

PLEASE PROVIDE A SCANNED OR PDF COPY OF WORKERS’ COMP ANNUAL DECLARATION PAGE, and/or WORKERS’ COMP MONTHLY PAYROLL REPORT, PAST 3 YEARS OF LOSS RUNS, CENSUS AND A CURRENT HEALTH BILL AS AN ATTACHMENT TO THIS EMAIL ADDRESS.

7. State Unemployment Tax Rate (SUTA):  

8. Do you have: (Check One)  Health      Dental       Vision      

Who is the Carrier? :

9. Do you have:   401(k)   125/Cafeteria Plan      Est. Annual Cost? :

10. Do you currently have an Employers Protection Liability Policy (EPLI) ? : Yes  No

 

*Work Phone
Your message: