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Company Information:

Company Name:

Years in Business:

Street Address

City

State

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Contact Name:

Title:

Phone:

Fax #:

Email:

PEO Services Needed: Check all that apply

Other / Special Services Needed:

Description of Operations:

Tell us about your Worker's Compensation Program:

Average Gross Payroll per Week:

Annual Payroll:

Does your company currently have workers' compensation coverage?

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Current Workers Compensation Carrier:

Policy Renewal Date:

Experience Modifier Rate:

Number of Claims in:

2024

2023

2022

2021

Employee Workers' Compensation Classification / Code / Annual Payroll

Classification(s):

Comp Code

Annual Payroll

Rate Per $100 of Payroll

Example

Total Annual Payroll:

State Unemployment:

Current Number of Employees:

W-2s processed last year:

Current State Unemployment Rate (SUI)

Number of unemployment claims in last 12 months:

Tell us about your Employee Benefits:

Do you currently provide Benefits to your Employees?YesNo

Other Benefits Provided:

Tell us about your current Business Insurance coverage: (Check all that apply)

General Liability

Errors & Omissions

Employer Practices Liability (EPLI)

Owned / Non-owned Automobile

Umbrella

Estimate of Present Administrative Costs (as a percent of payroll):

Administrative costs should include all costs associated with your company providing complete (1) Human Resources administration, (2) Workers' Compensation, Risk Management & injury claims administration, (3) Payroll processing and payroll tax compliance, (4) Unemployment Claims processing & (5) Group Benefits administration. (These costs must include all staff & management payroll, associated payroll taxes, benefits for staff employees in these departments; including vacation pay, holiday pay, the equipment and supplies they utilize, rent space, departmental utilities, legal fees, professional fees (all operating costs associated with the specific departments mentioned above).

For assistance in calculating your administrative costs, click here: Administrative Cost Calculator

Note: A recent Small Business Administration study showed an expenditure in the range of 4 - 12%, with an average of 8.43% of payroll costs to provide the above administrative services.

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