To request a proposal:
Please fill out the form below. All fields are required except Owner SSN.

1. Complete Name of Company:
Please include any DBA's.

2. Company Address:
Please include primary contact.

3. Detailed Company Description:

4. Tax I.D. Number:

5. Type of Business:

Sole Proprietor (1040 Schedule C)
Corporation (1120)
Partnership (1065)
S-Corporation (1120S)
Trust (1041)
Non-Profit Organization (990)

6. How Long in Business:

7. Owners of the Company:
Please provide information for each owner.

8. Breakdown of Payroll by Workers' Compensation Codes:
The first column is an example and should be used as a reference.

9. Email Address

10. Phone Number

Available Documentation:
Place a check in the box if the following documentation is available.

	Current Workers' Compensation Carrier and copy of Declaration page (showing annual renewal date and experience modifier)
	Copy of most recent medical insurance invoice (showing employees covered, dependents, and rates. Ages or birth dates if available)