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Business Information
Contact first name
Contact last name
Contact title
Contact Phone
Contact Email
Address
Who Referred You
Legal name
DBA
FEIN
Years in Business
Number of Employees
Description of Operations
Current Vendors
Current Payroll/PEO Vendor
Current Workers Comp Carrier
Workers Comp Experience Mod
Company Risk
How many Company Vehicles?
How many drivers?
What type of Company Vehicles?
What is the radius of the drivers?
How many 1099's/Independent Contractors
Workers Comp Payroll Information
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State
WC Code
Employees
Annual Payroll
State Unemployment Rate
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State
WC Code
Employees
Annual Payroll
State Unemployment Rate
Documents
PEO Invoices (If Applicable)
Max. file size: 300 MB.
Workers Comp Dec Page
Max. file size: 300 MB.
Workers Comp Loss Runs
Please attach the last 3 years of your Workers Comp Loss Runs.
Workers Comp Loss Runs
Max. file size: 300 MB.
Payroll Register
Max. file size: 300 MB.
Medical Census (If applicable)
Max. file size: 300 MB.
Medical Invoice (If applicable)
Max. file size: 300 MB.
Medical Renewal (If applicable)
Max. file size: 300 MB.
Medical Plan Summaries (If applicable)
Max. file size: 300 MB.
12 Months Medical Claims History (If applicable)
Max. file size: 300 MB.
Miscellaneous document
Max. file size: 300 MB.
State
WC Code
Employees
Annual Payroll
State Unemployment Rate
