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Request for Proposal

BUSINESS INFORMATION

Name of Company*

Address*

City, State & Zip*

Business Telephone*

Fax:

Contact Person*

Email Address*

Industry Type*

SIC Code:

Business Type*

S-Corp	Sole Proprietorship	C-Corp	Partnership
LLC	Other

Owner:

Date Established:

PAYROLL INFORMATION

Pay Frequency:

Weekly

Bi-Weekly

Semi-Monthly

Monthly

Unemployment State:

Please Provide Current Unemployment Rate:

BENEFITS OFFERED

Health insurance?	Yes	No
Dental insurance?	Yes	No
Vision insurance?	Yes	No
401(k) or 403-b Program?	Yes	No

NCCI # / Workers� Comp. Manual Code(s) and descriptions (example in italics):
Job Position	NCCI Class Code	Current Rate	State	No. of employees		Annual Payroll
Job Position	NCCI Class Code	Current Rate	State	FT	PT	Annual Payroll
Example: Clerical	Example: 8810	Example:4.3	OH	5	5	$200,000

An Administrative Employer Services Representative will be contacting you to follow up on your request for proposal.

AES reserves the right to review underwriting, loss history and facilities prior to acceptance. This is a request for proposal and in no way constitutes acceptance of client until underwriting has approved all aspects of client�s submissions.