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 Company InformationEntity TypePlease Select...CorporationPartnerIndividual/Sole ProprietorLLCLLPOtherYears in BusinessAdditional Locations Workers' Compensation InformationCurrent Insurance Company (not agency)Annual Premium AmountPolicy Effective Date Policy Expiration Date 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