Quote

Company & Contact Information * = required field

*Company Name

*Address

Address (cont.)

*City

*State

* Zip

*Contact Name

Title

*Phone

() -

FAX

() -

*E-Mail

Web Address

Would you prefer to be contacted by

E-mail
Phone

Give us a quick description of your business.

# of Employees Years in Business

Tell us about your payroll and workers' compensation breakdown

To form an accurate quote, we have to break down your employees into Workers' Compensation class codes. If you know your 4 digit class code (example: Clerical employees = 8810) then enter that number below with the corresponding number of employees and approximate weekly gross wages. If you don't know the comp. class code, just give us a job title

Workers' compensation Experience Modification Rate:

Job Performed	# Employees	Comp Code	Annual Payroll	Rate Per $100
			$	$
			$	$
			$	$
			$	$
			$	$
# of Comp Claims Last Year		$ Value of Claims		$

Unemployment and PEO History

Current State Unemployment Tax Rate:
# of Unemployment Claims Last Year:

Current PEO Admin Fee:

How did you hear about us?