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Company Name
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Services Of Interest to you

Health Insurance Workers compensation Insurance
401K Retirement Group Life Insurance
Safety Manuals Employee Assistance Programs
Life Insurance Risk Management Training
Cobra Admin Customized Employee Handbook
Direct Deposit Employee Assessment Tools
HR Consulting Customized Employee Training
Dental Insurance    
Federal Tax Number Union Affiliation Yes No
Business Number Fax
E-Mail Address Years in Business
Type of Business
Additional Business Location? If so where?
State Unemployment Tax Rate in Texas Other States
Number of Full Time Employees Part Time
Payroll Frequency Weekly Biweekly Monthly
Describe Operations (including all Worksites)
Does your Company have Multiple Operating Entities? Yes No


List Name and Type of entity

Workers Compensation Wage Information
State WC Class Code Position/Job #Employees Annual Wage
 
 
 
 
Do you have a safety manual and written safety policy?
(If yes, attach a copy)
Yes No
Do you conduct pre/post employment background checks on new hires for high hazard jobs?
(If yes, attach a copy of the program or policy)
Yes No
If available, please attach documentation of recent health and / or supplemental insurance bills

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If available, please attach a health insurance census showing employees and dependents

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