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SUBMIT INFORMATION FOR A QUOTE

Here is your opportunity to send information for a quote. Enter the information below and send it. We will review and respond directly to you.

If you'd like a customized quote for your business, please send us your information. We look forward to providing you with the best service available. Please make sure you provide your name, phone number and the best time to be reached. A brief description of your business can help jump start this process also. The more information the better.

Help expedite the process. Get started now!

 There is no cost or obligation on your part by completing the RFP, it only helps begin the process. All information is held in the strictest of confidence.

Some additional information that will be required in order to process your RFP is:
A declaration page from your existing workers' compensation policy
A report showing the Last three years of workers' compensation "loss runs"
A SUTA report or a notice indicating your current SUTA rate

Pricing Request
Name:
Email Address:
Company:
Tax I.D.:
Phone:
Fax:
Business Entity or Type:
Business Description:
Company Address:
City:
State:
Zip:
Company Website:
About Your Company
Number of Employees:
Work Comp Modifier:
If Known
Gross Payroll:
Per:

Gross Payroll-- Per Comp Codes:

The 4 digit number(s) listed on your workers' compensation certificate, such as "8810 - clerical"
Please leave Fields empty if you don't know your code(s)

Code 1:
Payroll/Code 1:
Code 2:
Payroll/Code 2:
Code 3:
Payroll/Code 3:
Code 4:
Payroll/Code 4:
Code 5:
Payroll/Code 5:
Code 6:
Payroll/Code 6:
Current Pay Cycle:
Current SUTA Rate:
State Unemployment Tax Rate (%)

Benefits of Interest:

 

 

Health Insurance
Dental Insurance/Vision
401 (K) Retirement Plan
Cafeteria 125 Plan
No Benefits
  

Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
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