Tri-State PEO - A Professional Employer Organization
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Company Information:
*Company Name
*Street Address
*City, State, Zip
*Contact Name   Title
*Phone #   Fax #
*Email
*Services Needed
# of Employees   Years in Business
Tell Us About Your Worker's Compensation Insurance Policy:
Policy Renewal Date: (mm/dd/yyyy) / /
Experience Modification Rate:
Classification(s): Comp Code   Annual Payroll   Rate Per $100
Example:    
#1:    
#2:    
#3:    
#4:    
#5:    
# Claims Last Year:
Tell Us About Your Employee Benefits:
Do You Currently Provide Benefits to Your Employees?
Yes   No
Benefits You Provide?
Medical   Dental   Vision   LTD   AD/D   401(k)
Other Benefits Provided:
Do You Sponsor All/Portion Of Employee's Cost?
Yes   No
How Did You Hear About Tri-State PEO?
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