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
MM slash DD slash YYYY
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:
MM slash DD slash YYYY
Policy Expiration Date:
MM slash DD slash YYYY
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

Class Codes or Description of job	State	Estimated Annual Payroll	Number of employees in Class Code

Basic Information

Referring Payroll Company

Company Information

Workers' Compensation Information

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