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General Info

Company *

Title

First Name *

Last Name *

Email Address *

Work Address *

City *

State *

Zip *

Country *

Work Phone *

Work Fax

Cell Phone

Business Location #2

Business Location #3

Tax Info

Fed ID Number

State UC ID Number

State UC Rate

Years in Business

Company Type Corporation
Partnership
S Corp
LLC
Sole Proprietor

Owner/Officer Info

Owner/Officer #1

Owner #1 Address

Owner #1 SSN

Owner #1 DOB

Owner #1 Ownership Percentage

Owner #1 WC Coverage Inclusive Exclusive

Owner/Officer #2

Owner #2 Address

Owner #2 SSN

Owner #2 DOB

Owner #2 Ownership Percentage

Owner #2 WC Coverage Inclusive Exclusive

Workers Comp Info

Proposed Effective Date

Experience MOD

WCIC1 State Code

WCIC1 SIC Code

WCIC1 Description

WCIC1 No. Full Time Employees

WCIC1 No. Part Time Employees

WCIC1 Est. Payroll

WCIC1 Rate

WCIC2 State Code

WCIC2 SIC Code

WCIC2 Description

WCIC2 No. Full Time Employees

WCIC2 No. Part Time Employees

WCIC2 Est. Payroll

WCIC2 Rate

Prev WC Carrier

Prev WC Policy Number

Prev WC Effective Date

Nature of Business

ProEmp WC Carrier

ProEmp WC Policy Number