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Company Information |
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Legal Business
Name (& dba) of Applicant: |
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Contact Name: |
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Street Address: |
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Telephone: |
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Fax: |
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Email: |
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Type of Entity: |
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Federal ID #: |
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Payroll, Workers
Comp. and Employee Info. |
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Present Workers
Compensation Carrier: |
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Current Payroll
Processed by: |
In-house
Payroll
Company |
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Leasing
Company (if so, please list
below) |
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Pay Cycle: |
Weekly
Bi-monthly |
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Semi-monthly
Monthly |
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Number of
Employees: |
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Description: |
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WC Classification
Code: |
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Annual Payroll: |
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Business Description |
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Years in
Business: |
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Description of
Operations: |
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