For form testing

Company Name:
Contact Name:
Phone Number:
Fax Number:
Location 1 Address:
Street Address City ZIP / Postal Code
Payrolls (annual):
Architects/Engineers
# of Employees
Surveyors
# of Employees
Drafting
# of Employees
Accountants
# of Employees
Attorneys
# of Employees
Clerical
# of Employees
Other:
# of Employees
Location 2 Address:
Street Address City ZIP / Postal Code
Payrolls (annual):
Architects/Engineers
# of Employees
Surveyors
# of Employees
Drafting
# of Employees
Accountants
# of Employees
Attorneys
# of Employees
Clerical
# of Employees
Other
# of Employees
Owners & Officers:
- Covered
- Excluded
Name of officers to be excluded:
Do you use QuickBooks payroll?
- Yes
- No
Federal Employee I.D. Number:
Current WC Insurance Carrier:
Expiration Date:
Experience Modifier:
Have you had any worker’s compensation claims within the past 3 years?
- Yes
- No
If yes, please explain:
CAPTCHA

Payrolls (annual):