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Our experts will create a custom cost analysis tailored to your business, and answer any of your questions about us or PEOs in general.

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Company Information:
*Company Name
*Street Address
*City, State, Zip
*Contact Name Title
*Phone # Fax #
*Email
*Services Needed
# of Employees Years in Business
Tell Us About Your Worker's Compensation Insurance Policy:
Policy Renewal Date: (mm/dd/yyyy) / /
Experience Modification Rate:
Classification(s): Comp Code Annual Payroll Rate Per $100
Example:
#1:
#2:
#3:
#4:
#5:
# Claims Last Year:
Tell Us About Your Employee Benefits:
Do You Currently Provide Benefits to Your Employees?
Yes No
Benefits You Provide?
Medical Dental Vision LTD AD/D 401(k)
Other Benefits Provided:
Do You Sponsor All/Portion Of Employee's Cost?
Yes No
Unemployment:
Current State Unemployment Tax Rate (SUI):
# of Unemployment Claims Last Year:
How Did You Hear About Quality Business Solutions?
If Other, please explain: