Please tell us about your company:
Company Name:
Street Address:
City:
County:
State:
Zip Code:
E-mail Address:
Phone Number:
( ) -   
Fax Number:
( ) -  
Person to Contact:
Title:
Type of Business:
Number of Locations:
What is your current
Worker's Compensation
experience MOD?
How often do you Pay
Your Employees?
Weekly
Bi-Weekly
Semi-Weekly
Please tell us about your employees:
Please use one line for each different job type and location

What type of job?

What state
are these employees located?

How many employees are in this state with this job type?

What is the average annual salary for these employees?

How many of these employees would like health insurance?

example:

Illinois

5

$35,000 annually

4

 $

 $

 $

 $

 $

Total Annual Salary:
 $