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Business Analysis Questionnaire


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

A. Company Information
First Name
Required
Last Name
Required
Legal Business Name (Include DMA)
Optional
Street Address
Optional
City, State
Optional
ZIP / Postal Code
Required
Telephone Number
Optional
Fax Number
Optional
Federal ID Number
Optional
Check One
Optional




Contact
Optional
Years in Business
Optional
Industry- SIC Code
Optional
Website Address
Optional
E-Mail Address
Required
B. State Unemployment Information- Fax the most recent State Unemployment Statement. Note: If you operate in more than one state, send statements from all.
Current Rate (Percentage)
Optional
Current Rate (Percentage)
Optional
Current Rate (Percentage)
Optional
Current Rate (Percentage)
Optional
C. Health and Dental Insurance Information- Fax the most recent Health and Dental Insurance invoices
Office Visit Co-Pay ($)
Optional
Deductible ($)
Optional
Drug Card ($)
Optional
D. Workers' Comp Information- Fax the most recent Workers' Comp Declaration Page- Fill out each section below for each job title (ie: clerical/8810, sales/8742)
Job Title and Code #1, Wokers' Comp Rate, Number of Employees, Annual Payroll
Optional
Job Title and Code #2, Wokers' Comp Rate, Number of Employees, Annual Payroll
Optional
Job Title and Code #3, Wokers' Comp Rate, Number of Employees, Annual Payroll
Optional
Job Title and Code #4, Wokers' Comp Rate, Number of Employees, Annual Payroll
Optional
E. General Information
Do you use payroll service?
Optional
If yes, what are the monthly fees?
Optional
Payroll frequency
Optional
F. Employee Information
Do you currently offer a 401(k) Retirement Plan?
Optional
Do you currently offer a Section 125 Cafeteria Plan?
Optional
G. Please fax a list of each employee's sex, DOB, age, and whether their current insurance is Single, Family, Employee/Spouse, or Employee/Children.
Please fax all requested documents to (586) 726-8835.
Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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