Please provide the following information to allow us to process a Proposal for you.

General Business Information

Legal Business Name and/or D.B.A. Name
Street Address
City
State
Zip Code
Primary Contact Phone?
Primary Contact Name?
Primary Contact Title?
Primary Contact E-mail?
Detailed Business Information
Industry Description ? Date Business Started ?
Secondary Contact Name? Secondary Contact Phone?
Secondary Contact Email ? Website URL ?

No. Full time employees ?

(30 hrs or more)		 Internet Connection ?
No. Part time employees ? States of employment ?
Avg. monthly gross payroll $ Approx. turnover rate ?
Drug Testing Policy (written) Any hazardous materials?

WORKERS' COMPENSATION INFORMATION

Obtain a copy of the Declaration Page from the current Workers' Compensation Policy
Description of Work
Class Code
No. of Employees
Expected Annual Payroll
$
$
$
$
$
$
$

Other Information:

 

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