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Please complete the following information to receive a Free Rate Quote. Administrative Concepts appreciates the opportunity to interact personally with you. One of our representatives will review your information promptly and provide you with the requested information. ALL INFORMATION IS KEPT STRICTLY CONFIDENTIAL. NONE OF THE DATA PROVIDED IS SHARED OR MADE PUBLIC IN ANY WAY. Please also feel free to Contact Us directly if we can be of any assistance.

COMPANY INFORMATION

Legal Business Name
(and d/b/a) of applicant:

Contact Name:

Street Address:

City:

State:

Zip:

Telephone:

Fax:

E-mail Address:

Type of Entity:

Federal ID#:

PAYROLL, WORKERS COMPENSATION AND EMPLOYEE INFORMATION

Present Worker's Compensation Carrier:

Current Payroll
Processed by:

In-house Payroll Company* Leasing Company*

Payroll or Leasing
Company*:

Pay cycle:

weekly
monthly

bi-weekly
semi monthly

# of Employees	Description	Workers Compensation Classification Code	Annual Payroll

BUSINESS DESCRIPTION

Years in Business:

Standard Industry Classification Code
(if known):

Description of Operations:

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