Name:

Business Name:

Your Role at the Company:

Company Owner:

Contact Person:

Email:

Phone Number:

Address:

EIN – Employer Identification Number:

Number of Employees:

Estimated Annual Payroll:

Describe the Type of Work Your Company Does:

Do you have Worker's Comp?
 Yes  No

Have you had Worker's Comp in the last three years?
 Yes  No

Worker's Comp Code Number (if you know):

Have You Used a Payroll Service Before?
 Yes  No

Have You Used a PEO before?
 Yes  No

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