Payroll Partner Request A Quote Workers' Comp Request a Quote 1 Required Information2 Additional Information Basic InformationLegal Name of Business*Federal TaxID Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Business/Description of Operations*Contact Name*Contact Phone Number*Contact E-Mail* Best Time to Call : HH MM AM PM Referring Payroll CompanyPayroll Company Name*Payroll Rep Name*Phone*E-mail* This Company isExisting ClientProspectPayroll FrequencyPlease Select...WeeklyBi-WeeklySemi-MonthlyMonthlyFirst Check Date Date Format: MM slash DD slash YYYY Company InformationEntity TypePlease Select...CorporationPartnerIndividual/Sole ProprietorLLCLLPOtherYears in BusinessAdditional Locations Workers' Compensation InformationCurrent Insurance Company (not agency)Annual Premium AmountPolicy Effective Date Date Format: MM slash DD slash YYYY Policy Expiration Date Date Format: MM slash DD slash YYYY Class CodesClass Codes or Description of JobStateEstimated Annual PayrollNumber of Employees in Class Code Have there been Injuries or Losses in the Last 4 Years?YesNo