Fill in Our Online Request for Proposal or Click Here for a Printable form in PDF
   Request For Proposal
General Information
Today's Date: JR Sales Rep: Proposal Agreement Both
Client Contact: Client Title:
Agent Name: Agent Phone: Agent Fax:
Agent E-mail Address: Date Needed:
Proposal - Agreement Information
Legal Name:
Street Address: City/State/Zip:
D/B/A Name:
Mailing Address: City/State/Zip:
Telephone: Fax Number:
Web-Site: No Yes                If Yes, Web-Site Address:
Total Annual Payroll: Total # of Employees:
FEIN: Incorporation State:
Corporation Sole Proprietorship Professional Assoc. Partnership Limited Liability Company Not-for-Profit
Nature of Business: 
Years In Business:
Payroll Information
Pay Frequency: Weekly Bi-Weekly Semi-Monthly Monthly - Pay Begin Day: Pay End Day:
Currently w/ PEO: No Yes         -         If Yes, Who: How long with current PEO
Part time Employees: No Yes         -         If Yes, how many:
SUTA Rate:   SUI Tax number:
Job Costing: No Yes                 Certified Payroll: No Yes                 Other Info:
Benefits Administration
Benefits: Medical/Dental  Supp Life  LTD STD  401(k)  Other Voluntary
Subscriber Plan(s): Medical 401(k) Other Benefits/Plans  Sec.125
Will PEO Deduct for Client plan(s)?: No Yes
Workers' Compensation Administration
Formal Safety Program Client Workers' Compensation Plan Client Drug-Free Work Place Program
Drug Free Program:    Pre-Employment   Post-Accident    Reasonable Suspicion   Random      (Post-Accident Required)
Class Code Description
WC Class Code
Number of Employees
Est. Annual Payroll
Worker's Compensation Information
Loss Control Pre-Survey Contact: Agent  First Customer Direct
Other Issues or Concerns:
  Yes No
Does applicant own, operate or lease aircraft/watercraft?
Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or ransporting of hazardous materials (landfills, wastes, fuel tanks, etc.)
Any work performed underground or above 15 ft.?
Any work on barges, vessels, docks, bridge over water
Is applicant engaged in any other type of business?
Are subs used? (If yes, specify % of work contracted in notes section.)
Any work sublet without certificates of insurance?
Is there a written safety program in operation?
Any group transportation provided?
Any employees under 16 or over 60 years of age?
Any seasonal employees?
Any volunteer or donated labor? 
Has applicant been inspected by OSHA in the past 3 years?
Was applicant cited for any violations?
Any employees with physical handicaps?
Do employees travel out of state?
Are athletic teams sponsored? 
Are physicals required after offers of employment are made?
Any other insurance with this insurer?  (Cedar Hill / Zurich)
Any prior coverage declined/cancelled/non-renewed?(last 3 yrs)
Are employee health plans provided?
Is there labor interchange with any other business/subsidiary?
Do you lease employees to or from other employers?
Do any employees predominantly work at home?
Any tax liens or bankruptcy within last 5 years?
Any undisputed work comp premium due from you or any commonly  managed or owned enterprises?  (If yes, explain in notes section including entity name & policy numbers.)
Please provide an explanation for any ‘Yes' answers in the section below.
Submission Requirements Check-List
Workers Compensation loss runs, last 3 years
Workers Compensation policy declarations page
Most recent SUTA report or confirmation of current State Unemployment Rate (UCT-6, If available.)
Copy of last PEO invoice or payroll report
Current copies of benefit plans and monthly billing (only if interested in group medical pricing)
Complete description of operations on your company letter head.
Explanation for Missing Requirements   (Explain below or attach separately for ANY requirement not provided with this RFP)
Additional Comments
Do you have commissioned, tipped or piecework employees?
Do you use an accrual system to track vacation and sick time?
Do you require payroll reports by department or job?
Do you require or prefer internet payroll?
Would you prefer assistance with job descriptions or employee handbooks?
Do you want to offer your employees benefits offered by a PEO?
Do you want to offer a retirement program such as a 401k plan through a PEO?
Are you willing to contribute up to 75% of the employee premium towards a health plan?
Do you currently offer any employee benefits?
Do you require a minimum premium w/c policy?
Do you work on OCIP Jobs, (Owner Controlled Insurance Program)
Do you perform work or have locations in other states?  If yes, please list states.