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COMPANY INFORMATION
Legal Business Name:

Contact Name:

Street Address:

City:

State:
Zip:
 
Telephone:
 
Fax:
 
E-mail Address:
 
Type of Entity:
 
Federal ID#:
 
 
PAYROLL INFORMATION
Worker's Comp
Carrier (Current):
 
Payroll Processed
by (Current):
  In-house Payroll Company Leasing Company
Company:
 
Pay cycle:
  weekly
monthly
semi monthly
bi-weekly
bi-monthly
 
EMPLOYEE INFORMATION
# of Employees
Description
Classification
Code
Rate per $100
Annual
Payroll
 
BUSINESS DESCRIPTION
Years in Business:
 
SIC Code:
 
Description of Operations: