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
B. State Unemployment Information- Fax the most recent State Unemployment Statement. Note: If you operate in more than one state, send statements from all.
C. Health and Dental Insurance Information- Fax the most recent Health and Dental Insurance invoices
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
Job Title and Code #2, Wokers' Comp Rate, Number of Employees, Annual Payroll
Job Title and Code #3, Wokers' Comp Rate, Number of Employees, Annual Payroll
Job Title and Code #4, Wokers' Comp Rate, Number of Employees, Annual Payroll
E. General Information
Do you use payroll service?
F. Employee Information
Do you currently offer a 401(k) Retirement Plan?
Do you currently offer a Section 125 Cafeteria Plan?
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.
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
Per the terms of our
we will not resell your information to any third-party.