Please use this form to request a quote. To ensure the quickest turnaround and most accurate quote, please fill out as much information as possible.
Referral / Broker Name
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Your Name (*)
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Your Email (*)
Please enter a valid email address.
Your Title (*)
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Company Name (*)
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Company Website
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Company Address (*)
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Company City (*)
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State (*)
AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
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Zip (*)
Please enter a valid zip code.
Owner Name
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Business Phone (*)
Please enter only digits for your phone number. For example, if your phone is 972-555-1212 enter 9725551212.
Business Fax
Please enter only digits for your phone number. For example, if your phone is 972-555-1212 enter 9725551212.
Services of Interest
Workers Comp Coverage Payroll & Tax Administration Medical & Dental Coverage Life Insurance Coverage Safety & Risk Consulting Human Resource Consulting Employee Management
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Fed Tax ID (*)
Please enter a valid federal tax ID (digits only).
Years in Business (*)
Please enter a valid number between 0 and 100.
Nature of Business (*)
This is a required field.
Business Locations (*)
Please list all company locations.
This is a required field.
Operating Entities
If you have multiple operating entities, list each one here.
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Number of FTE's
Number of full time employees.
Please enter a valid number > 0.
Number of PTE's
Number of part time employees.
Please enter a valid number >= 0.
Your Texas SUTA Rate
Please enter a valid number.
Payoll Frequency (*)
Weekly Bi-Weekly Monthly Semi-Monthly
Please choose an option from the dropdown.
Pay Period Begins (*)
For example, "Mondy" or "1st Day of Month".
This is a required field.
Pay Period Ends (*)
For example, "Sunday" or "Last Day of the Month".
This is a required field.
Pay Date (*)
For example, "Friday" or "15th and Last Day of the Month".
This is a required field.
Employee WC Class Codes (*)
WC Deductible
Current WC deductible.
Please enter a valid dollar amount.
WC Policy Renewal Date
Date your current WC policy renews.
Please enter a valid date.
Health Deductible
Current health deductible.
Please enter a valid dolar amount.
Health Copay
Current health plan copay.
Please enter a valid dollar amount.
Health Renewal Date
Current health plan renewal date.
Please enter a valid date.
Current Safety Manual
If you have a safety manual and / or written safety policy, please attach a copy.
Files must be of type DOC, PDF, RTF, TXT, DOCX, XLS, JPG or JPEG.
Background Check Policy
If you conduct pre/post employment background checks on new hires for high hazard jobs, a copy of the program or policy.
Files must be of type DOC, PDF, RTF, TXT, DOCX, XLS, JPG, or JPEG.
Recent Health / Ins. Bills
If available, please attach documentation of recent health and/or supplemental insurance bills.
Files must be of type DOC, PDF, RTF, TXT, DOCX, XLS, JPG, or JPEG.
Employee Census
If available, please attach a health insurance census showing employees and dependents.
Files must be of type DOC, PDF, RTF, TXT, DOCX, XLS, JPG, or JPEG.
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