Quote for Propay PEO Services: Propay - Professional Employer Organization

Option 1

Complete the online request form below and send the additional information below. We'll give you a call in the next 24-48 hours.

Option 2

Print the request form, complete it off-line and fax the form along with the additional information below.

*In addition to the request, please email or fax the following information*

• Current declaration page from current work comp policy

• Last three years of work comp "loss runs"

• A State Unemployment Notice indicating current rate

If you would like tentative pricing without sending the above information, simply fill out the form below. Please understand the above paperwork will be required for final approval.


PRICING REQUEST - Serious Inquiries Only (Asterisked fields are required)

* Contact Name

* Company Name:

* Tax ID or Social:

* Business Entity Type:

* 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

*Gross Payroll--	Code 1:	Payroll/Code1:
Per Work Comp Codes	Code 2:	Payroll/Code2:
	Code 3:	Payroll/Code3:
	Code 4:	Payroll/Code4:
	Code 5:	Payroll/Code5:
	Code 6:	Payroll/Code6:

*Current Pay Cycle:

*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)



*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