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Total number of pages:_____________ Fax complete submission to 877.540.0878 Prepared By: Date Submitted Date Needed # of Proposals
Customer Legal Name (Include DBA if necessary) Address City, State & Zip code Phone Number FEIN# Main Contact Name Secondary Contact Title Title SIC Cod e Fax Number NCCI Risk ID# Email Address Email Address Web Site
Please Check One: [ ] C Corp [ ] S Corp [ ] LLC [ ] Partnership [ ] Proprietorship [ ] Non-Profit Unemp. Tax Rate# of Full Time EEs # of Part Time EEs # of Locations Years in Business
SUBMIT THE FOLLOWING DOCUMENTS WITH YOUR COMPLETED REQUEST FOR PROPOSAL [ ] Workers' compensation declaration page [ ] Three years workers' compensation loss history [ ] Most recent state unemployment tax report Contact Numbers: 954.540.5205 Direct 877-540-0878 - Fax adamcorin@nirocconsultants.com
[ ] If in a PEO relationship copies of billing report dating January and most recent billing report [ ] Detailed employee census to include name, DOB, gender, coverage elected, annual comp [ ] If no prior workers compensation coverage, provide bio on owners
Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho * State FundedSt
New Mexico New York North Carolina North Dakota * Ohio * Oklahoma Oregon Pennsylvania
Are there any unusual working conditions? [ ] Yes [ ] No Service provided 24 hours a day [ ] Yes [ ] No Major operations outside the state [ ] Yes [ ] No Heavy equipment (Ex. cranes, bulldozers, cherry pickers) [ ] Yes [ ] No Home health care [ ] Yes [ ] No Armed guards [ ] Yes [ ] No Pest control [ ] Yes [ ] No
Payment Type Requested (Check One): [ ] Automatic Debit [ ] Certified Funds [ ] Wire Transfer Co-Owner First Name: Address City, State & Zip Last Name: Phone Number
I understand a proposal cannot be generated unless application is complete. I hereby certify that all answers and information on this request for proposal are true and accurate to the best of my knowledge. I understand that any information found to be false or if any representations are found to be false it is grounds for termination of the Client Service Agreement to include cancellation of any and all coverage(s) extended. Submitting this request for proposal is in no way a guarantee of acceptance. ______________________________________________________________________________________ Controlling Person Name Signature Date ______________________________________________________________________________________ Co-Owner Name Signature Date ______________________________________________________________________________________ Account Executive Name Signature Date