Tri-State PEO will treat all information as confidential and use it exclusively for the purpose of preparing a custom tailored business proposal.   Fill out the form   * = required fields 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? Yahoo Google AOL Alta-Vista Lycos MSN InfoSpace Radio Ask Jeeves Business.com NAPEO Television Direct Mail Other If Other, please explain: How Did You Hear About Us ? Are you w/ a PEO/HRO Yes No             Tri-State PEO will provide a Detailed analysis of current costs and potential savings by joining our services.