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Company Name		Today's Date

Contact Person		Phone Number

Fax Number		Street Address

City		State		Zip Code

Federal ID#		Type of Work Done

Present Comp Carrier		Number of Claims in Last 3 Years		Years in Business

SUTA Rate (State Unemployment Tax Rate)

Legal Status Corporation Sole Prop Partnership

Payroll Frequency Weekly Bi-Weekly Semi-Monthly Monthly

The following information comes from your current Worker's Comp Policy.

W/C Class (Job Description)		Number of Employees

W/C Code		W/C Rate		Expiration Of Workers Comp Policy

Estimated Annual Payroll

Other Insurance Needs? LIABILITY    AUTO    TELESCOPE INFORMATION    INLAND MARINE    Other

Shall We Prepare A Payroll Quote For You? YES NO