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Home > Business Analysis Questionnaire
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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 *
Last Name *
Legal Business Name (Include DMA)
Street Address
City, State
ZIP / Postal Code *
Telephone Number
Fax Number
Federal ID Number
Check One






Contact
Years in Business
Industry- SIC Code
Website Address
E-Mail Address *
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)
Current Rate (Percentage)
Current Rate (Percentage)
Current Rate (Percentage)
C. Health and Dental Insurance Information- Fax the most recent Health and Dental Insurance invoices
Office Visit Co-Pay ($)
Deductible ($)
Drug Card ($)
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?
If yes, what are the monthly fees?
Payroll frequency
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.
Submission Validation
Required

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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