Request for PEO Quote

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Proposed Effective Date
Company Name
Address Street
Address (Line 2)
Address (Line 3)
     City
     State (XX)
     Zip
Phone
Fax
Email
Contact Name
Title
FED. ID #
General Liability Carrier
Policy Expiration Date

Description of Operations

 

Years in Business: 
Multiple Locations?  if Yes, How Many?
List States Operating In:

Workers' Compensation / Payroll

Current Carrier:

Job Title

Comp Code

Current Rate

# of Employees

Estimated Annual Payroll
1.  $
2.  $
3.  $
4.  $
5.  $
6.  $
7.  $
8.  $
9.  $
10. $
Totals

$
State Unemployment Tax Rate:

Payroll Frequency (select one)  W BW SM M

 

Benefits Information

Health Carrier
Coverage Level Plan Cost Per Month # of Participants Portion Paid by Employer
Employee
Employee and Spouse
Employee and Children
Employee and Family
Dental:
Cafeteria 125
Retirement Plans
Vision
Life Insurance
L-T Disability
S-T Disability
Plan Type

 

 

Please enter any additional comments in the space provided below:

 

I attest that the information in this request for proposal is,  to the best of my knowledge, correct. I also agree that if the information presented materially changes between the date of submission and the date of quote I will report such change in writing to Wyman and Associates, Inc.

 

 

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Copyright © 2003 Wyman and Associates, Inc. All rights reserved.
Revised: February 05, 2006 .