Workers Compensation Questionnaire

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Workers Compensation Questionnaire

Company Information
Legal Business Name
EIN#
Business Type (Inc, LLC) other
Years in Business
Physical Address
Email
City		State
Zip		Phone
Fax		Website
Description of operations (be specific with at least 3 sentences)
Annual Limits	100k/500k/100k 1m/1m/1m
Do you currently have a policy	Yes No
If yes, please list carrier and policy number
Owner(s) or Officer(s) Information
Name
Title
Social Security Number		Date of Birth
Will this person be covered?	No Yes
On payroll ?	No Yes
If yes, annual income
Name
Title
Social Security Number		Date of Birth
Will this person be covered?	No Yes
On payroll ?	No Yes
If yes, annual income
Employee Information
Class Code	Description/Duties	# EE’s /Annual Payroll

"We took advantage of the a la carte services and received the best group medical plan with HR consulting. PEO Edge was the only company that would allow us to keep our current payroll provider while still offering other services. You are one of a kind PEO Edge"

Sherry M from Austin, TX

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