*First Name:	Last Name:
*Address:       *City:      *State:  *Zip:
*Phone:           *Email:           *Best method of contact: Phone Email
* Year business started:	FEIN#:
Is this a seasonal business or one-time event?	Yes No
* Approximate amount of workers compensation claims paid in the last 3 years:	None $500-999 $1,000-1,999 $2,000-2,999 $3,000-3,999 $4,000-4,999 $5,000-7,499 $7,500-9,999 $10,000-19,999 $20,000-29,999 $30,000-39,999 $40,000-49,999 $50,000-74,999 $75,000-99,999 $100,000-149,999 $150,000-199,999 $200,000-249,999 $250,000-324,999 $325,000-399,999 $400,000-499,999 $500,000-599,999 $600,000-699,999 $700,000-799,999 $800,000-899,999 $900,000-999,999 $1,000,000+
What is your business legal entity?	Make a Selection Corporation S Corporation Limited Liability Company Limited Liability Partnership Partnership Sole Proprietorship Limited partnership Professional Corporation Nonprofit Corporation
What industry is your company in?
* Description of the nature of business: (Please be as detailed as possible)
* Describe the job function of employees:
Does your business offer health insurance to the employees?	Yes No If Yes, Renewal Month of Health Plan: Select a Month January February March April May June July August September October November December
* Please list your most recent calendar year gross payroll:	Make a Selection Under $100,000 $100,000-249,999 $250,000-499,999 $500,000-999,999 $1,000,000