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Save up to 40% on your workers' compensation insurance premiums and up to 20-25% on your health insurance premiums with average single digit renewals.

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First Name:*

Last Name:*

Email:*

Phone Number:

Number of Employees?

Your Business Information:

Company Name:*

Address:

City:

State:

Zip Code:

FEIN:

Website:

Detailed Description of Operations

Payroll Information:

Total Gross Payroll:

Total Number of Employees:

State Unemployment Tax Rate(SUTA):

Upload Payroll Register:

Acceptable file types: doc,docx,pdf,txt,gif,jpg,jpeg,png.
Maximum file size: 15mb.

Workers' Compensation Insurance Information:

Upload Workers Compensation Declaration Page(typically first three pages of policy):

Current Policy Effective Date:

Upload Loss History Report(36 months):

Health Insurance Information:

Current Healthcare Renewal Date:

Current Healthcare Plan Designs:

Current Healthcare Invoice(also showing election coverage levels):

Renewal Letter (if renewing within 60 days):

Employee Census:

Download Employee Census Template Here-Employee Census Template

Group Health Questionnaire:

Download Group Health Questionnaire Form Here-Group Health Questionnaire Template

Additional Information:

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