PayrollComp.com

 

 

 

 Pay As You Go Work Comp Insurance

 the program for payroll company clients.

 

Pay As You Go Workers' Compensation-Insurance Shop Logo

 

 

 

Questions? Call M-F 8:00am-6pm CST

(888).611.SHOP (7467)

Payroll Workers Compensation- Main Top Bar

 

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Get PayGo Work Comp Quotes

 

  (Six convenient options below)

Payroll Company Workers Compensation Program Check Mark   We make it easy to get PayGo work comp and GL quotes.


 

Helpful Docs:

Lead Referral Form

Work Comp Loss Affidavit

Work Comp Application- Acord 130

1.  Call Us: 888.611.7467
 
2.  Fax Us: 888.583.3110
 
3.  Email Us info@insuranceshopllc.com
 

4.  Upload Files:

 
 

Message:

 

 
 5.  Have a PayrollComp Broker call me:
Name:
Phone Number:

     6.  Online Submission Form:

Name of Business:

Name of Owners/Officers:

 

Contact Name:

Contact Phone & Fax:

 Phone:    Fax:

Contact E-mail Address:

Address:

 

City:

 

   State:    Zip:

Business Info:

C-Corporation
S-Corporation
LLC                

Sole-Proprietor

Partnership

LLP/Other

 Years in Business:

Fed. Tax ID or Social Security Number:

Business Description:

     Current/Previous Insurance Information

Current insurance company:

   Annual Premium:

Policy Period:

 Effective Date:    Expiration Date:

Work Comp Modifier:

(if Known)

Will Owners be Included or Excluded- Please Explain:

Additional Owner Info:

Any Other Carriers

(last 3 years):

 

No  Yes   If yes, please list name and estimated premium:

Any Insurance Claims Filed

(last 3 years):

 

 

 

No  Yes   If yes, please give following data:

 -Date of claims, amount of claims, description, and cost of claims:

     Payroll  & Class Code Information

Class Code

or Job Description

# FT Employees

# PT Employees

Estimated Payroll

per Class Code

     Other Information

List any additional Locations:

 

Do You Require Coverage Above Mandatory Limits:

No  Yes   If yes, please describe required limits:

Do You Work Outside

 of Your State:

No  Yes 

Do you use a payroll company:
If so, what company:

     Additional Comments & Information

Please tell us anything else you think might be helpful to know in order to provide accurate insurance quotes:

 

 

 

Payroll Company Workers Compensation Program Check Mark  Get fast quotes with us


 

 

 Workers Compensation Pay As You Go Payroll Cycle Picture

 

PROGRAM INFORMATION

PARTNER FORMS & DOCUMENTS

SERVICE LINKS

OTHER INSURANCE PRODUCTS

 

 

 

 

Payroll Program for Workers Compensation- Contact Us Picture

 

 

 

 

 

 

 

 

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All rights reserved.  Columbia, Missouri- MO

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