Payroll Partner Request a Quote

Please fill out the form below with appropriate detail and click the “Submit” button to send your quote request. Fields marked with an asterisk (*) are required. Other fields may be left blank, but the more information you can provide, the better.

Basic Information
Legal Name of Business:*
Federal Tax ID Number:*
Number of Employees
Address
Street Address Address Line 2 City State ZIP Code
Type of Business/Description of Operations*
Contact Name:*
Contact Phone Number:*
Contact E-Mail:*
Referring Payroll Company
Payroll Company Name*
Payroll Rep Name*
Phone*
E-mail*
This Company is
- Existing Client
- Prospect
Payroll Frequency
First Check Date
Would you like to add additional information?
- Yes
- No
Company Information
Entity Type
Years in Business:

Additional Locations

Workers' Compensation Information
Current Insurance Company (not agency):
Annual Premium Amount
Policy Effective Date:
Policy Expiration Date:
Class Codes
Class Codes or Description of job State Estimated Annual Payroll Number of employees in Class Code
Have there been Injuries or Losses in the Last 4 Years
- Yes
- No

Basic Information

Referring Payroll Company

Company Information

Workers' Compensation Information