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What line of business is your company in?
Other (please specify):
How many employees do you have?
How many Full Time and Part Time Employees do you have?
Full Time
Part Time
Seasonal
Do you currently process New Hire Reporting?
Yes No 
How do you process your payroll?
In-House 
Payroll Service 
Accounting Service 
Other 
Do you currently offer an Orientation Package for New Hires?
Yes No 
Do you have an Employee Manual?
No - We do not have an Employee Manual 
Yes - We have an Employee Manual 
Yes - We have an Employee Manual but it has not been updated recently 
For each of the following benefits please select the most appropriate answer  *
Not Offered Satisfied With Current Looking for Options Want to Improve
Medical Insurance Medical Insurance Not Offered Satisfied With Current Looking for Options Want to Improve
Dental Insurance Dental Insurance Not Offered Satisfied With Current Looking for Options Want to Improve
Vision Insurance Vision Insurance Not Offered Satisfied With Current Looking for Options Want to Improve
Short Term Disability Short Term Disability Not Offered Satisfied With Current Looking for Options Want to Improve
Long Term Disability Long Term Disability Not Offered Satisfied With Current Looking for Options Want to Improve
401(k) or Retirement Program 401(k) or Retirement Program Not Offered Satisfied With Current Looking for Options Want to Improve
Employee Perks Program Employee Perks Program Not Offered Satisfied With Current Looking for Options Want to Improve
Fitness Club Membership Fitness Club Membership Not Offered Satisfied With Current Looking for Options Want to Improve
What is your annual "Payroll"?
What are your Workers Compensation Class Codes (List up to 5)?
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5.
In the same order, enter the annual payroll dollars per Workers Compensation class code.
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2.
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5.
In the same order, enter the number of employees per Workers Compensation class code.
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2.
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5.
Please list any special comments, issues, or questions regarding your company here:
Please provide your contact information:
Name
Company
Address
City/Town
State
ZIP/Postal Code
Email Address:
Phone Number:
* IES is not an insurance agent or licensed to sell or service insurance. For more information regarding insurance coverage plans contact Union One. (www.uniononegroup.com)
    

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