PRICING REQUEST - Serious Inquiries Only (Asterisked fields are required)
     
     
* Contact Name
  
     
* Company Name:
  
     
* Tax I.D. or Social:
  
     
* Business Entity Type:
  

C-Corporation
S-Corporation
LLC
Partnership
Sole-Proprietor
LLP/Other

     
* Company Address:
  
     
* City:
  
     
* State:
  
     
* Zip:
  
     
Company Web Site :
  
     
* Email Address :
  
     
* Re-Enter Email:
  
     
* Phone Number:
   ( )
     
* Re-Enter Phone Number:
   ( )
     

ABOUT YOUR COMPANY
     
* Number of Employees:
  
     
* Work Comp Code(s):
  
    The 4 digit number(s) listed on your workers' compensation certificate, such as "8810 - clerical"
     
Work Comp Modifier:
(if known)
  
     
*Gross Payroll:
  
 per
   Week
Bi-Weekly
Semi-Monthly
Monthly
Annually
     
*Gross Payroll--
   Code1: Payroll/Code1:
Per Work Comp Codes
   Code2: Payroll/Code2:
    Code3: Payroll/Code3:
    Code4: Payroll/Code4:
    Code5: Payroll/Code5:
    Code6: Payroll/Code6:
       
*Current Pay Cycle:
   Weekly
Bi-Weekly
Semi-Monthly
Monthly
Annually
     
*Current SUTA Rate:
   State Unemployment Tax Rate (%)
   
Benefits of Interest:
   Health Insurance
(check all that apply)
   Life Insurance
    Dental Insurance
    Vision Insurance
    401 (k) Retirement Plan
    Pre-Tax Cafeteria 125 Plan
    No Benefits
     
     
Additional Questions/ Comments:
  
     
How did you hear about us?
(select one)
  

Google
Yahoo
MSN
Other Search Engine
Yellow Pages
 Other
     
       
*In addition to the request, we need the following information e-mailed or faxed to us*

• Current declaration page from current work comp policy
• Last three years of work comp "loss runs"
• A State Unemployment Notice indicating current rate

dwatson@propaypeo.com : fax 352-376-6140