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is proud to partner with E_COMP for
Workman's Compensation
coverage seamlessly interfaced with our Payroll product
Please complete and submit the form below and
we will have a quote for you very quickly.
Workers’ Compensation Questionnaire
Company Name
Email
*
First Name
Last Name
Job Title
E_COMP Desired effective date of coverage
Month
/
Day
/
Year
E-COMP Legal Business Name
*
E_COMP Any DBAs? (Doing business as)
E_COMP Enity Type?
Please Select
Sole Proprietor
Partnership
LLC
C Corporation
S Corporation
Nonprofit Organization
Cooperative
Limited Partnership
E_COMP All Physical Addresses?
E_COMP Mailing Address?
E_COMP FEIN # (Federal employer identification number)
E_COMP Detailed business description of operations
E_COMP Estimated Annual Payroll (for employees)
*
E_COMP Please list your owners names, Titles and % Ownership
E_COMP Current policy Carrier?
E_COMP Expiration Date of current policy
Month
/
Day
/
Year
E_COMP Any worker's comp clains in the past three years?
Please Select
Yes
No
E_COMP Do you have any 1099 workers or subcontractors? If so please list the services beinbg subcontracted.
Submit