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In order to receive a response via E-mail, please submit the following information about your business. The fields required for a response are indicated with an *. All other information is optional, but is necessary for us to provide you with a quote. Please include as much information as possible.

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*Company Name

*Address

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*City

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*Contact Name

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*Phone

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*E-Mail

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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		$

Other Information

Current Unemployment Tax Rate (if known):
Your mod rate (if known)

Current PEO Admin Fee: (if known)

How did you hear about us?

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