Request for Quote
Company Name
Street Address
City
Zip
State
Contact Information - Please Complete ALL Sections
Contact Name
Contact Title
Contact Phone
Contact Fax
Contact Email
Ext.
Payroll Processing Information - Please Answer ALL Questions
What is Your Processing Frequency
Please Select One of the Above
What is Your Average Number of Checks per Pay Period
If "YES" Enter the Number of Direct Deposits. If "NO" Enter "0".
Do You Want Direct Deposit
How Will You Enter, Prepare and Report Your Payroll
My Needs Are:
Optional Products and Services
Are You Interested in Obtaining a Quote for Any of These Products and/or Services
Please Check All That Apply
Workers' Compensation Information for Existing Insureds or New Businesses
1.)
2.)
3.)
4.)
5.)
Having All Employees on Direct Deposit Will Eliminate ALL Shipping Charges
Describe in Detail What Work You Perform
Date Business Started (mm/dd/yyyy)
Number of Employees - Full Time Part Time
Estimated Annual Payroll
Existing Businesses - Existing Coverage
New Businesses - No Existing Coverage
Current Carrier
Bureau File Number
List All The States You Conduct Business In - or - Have Employees In
WC Class Code(s) - Please copy the information exactly how it appears on your existing policy
Experience Modification
Inception Date (mm/dd/yyyy)
Expiration Date (mm/dd/yyyy)
F.E.I.N.
Do You Sub-Contract Work
% of Work Sub-Contracted
Code
Class Code Description
State
Est. Ann. Payroll
# of EE's
FT
PT
FT
FT
FT
PT
PT
PT
1.)
2.)
3.)
4.)
1.)
2.)
3.)
F.E.I.N.
Please Select One of the Above
