4 Decades of Proven Success! Employee Login Request for Information / Proposal Company Legal Name: Date: MM/DD/YYYY Company DBA: Phone: Company Address Line 1: Fax: Company Address Line 2: Cell: Owner's Name: Email: Contact Name: Email: Type of Business: Federal ID Number: State ID Number: General Client Information How Long in Business: Payroll Cycle: choose one Weekly Bi-Weekly Monthly Semi-Monthly Current State Unemployment Tax Rate (SUI): % Current Payroll Provider: Monthly Cost $: Workers Compensation Insurance Carrier: Workers Compensation Experience Modification: % W/C Class Code: # of Employees: Monthly Payroll: 401(K) Provider: Cost: $ Health Insurance Provider *: Dental Insurance Provider *: Dental Insurance Provider *: * Supply 3-4 years work comp loss runs. 22695 Old Canal Road, Yorba Linda / California 92887-4601 / (714) 921-3700 / (800) 833-8369 / FAX (714) 921-3124 Thank you! We will contact you shortly.
