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Worker’s Compensation Premium Estimate
Workers Comp Premium
Customer Name
*
Office Phone
*
Mobile Phone
Mailing Address
*
Mailing Address
Mailing Address
Mailing Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Website/URL
Email
Entity Type
Sole Proprietor
Corporation
LLC
Trust
Unincorporated Association
Partnership
Subchapter “S” Corp
Joint Venture
Other
Year Business Card
Federal Employer ID Number
*
Description of Operations
*
Current Workers’ Compensation Policy
Drop a file here or click to upload
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Maximum upload size: 30MB
Locations
Location Number
*
Highest Floor
*
Address
*
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Add
Remove
Policy Information
Proposed Effective Date
Proposed Expiration Date
Normal Anniversary Rating Date
Part 1 – Workers Comp (States)
Text
Part 2 – Employer’s Liability
$100,000 / $500,000 / $100,000
$500,000 / $500,000 / $500,000
$1,000,000 / $1,000,000 / $1,000,000
Experience/Merit Modification
State
Factor
Expiring/Target Premium
Individuals Included/Excluded
Partners, Officers, Relatives (Must be employed by business operations) To be included or excluded (Remuneration/Payroll to be included must be part of rating information section.) Exclusions in Missouri must meet the requirements of Section 287.090 RSMo.
State
Location Number
Name
Date of Birth
Title/Relationship
Ownership %
Duties
Include
Exclude
Class Code
Renumeration
Add
Remove
State Rating Worksheet
Company Name
*
Name
*
Email
*
Phone Number
*
Add
Remove
Loss History
Please list all claims from the past 5 years. Date / Type / Amount Paid
Date
If you are human, leave this field blank.
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See Our Google Reviews
AccuPay HCM
5.0
Based on 1 reviews
Charles Whitt
01:10 17 Sep 21
Great staff, superior customer service and a great platform to manage your employee base.
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