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Netpay Insurance's Workers Compensation Page.		  

Client:
Address:  
Netpay contact  
Primary contact for workers comp
First Name:  
Last Name:  
Telephone:  
Fax  
Email:  
Federal ID#  
Ownership Information
Officer Percentage owned %
Title  
Officer 2 Percentage owned %
Title 2  
Officer 3 Percentage owned %
Title 3  
Class Code: Estimated Annual Payroll: Number of Employees
Class code Number of EEs
Estimated Payroll Rate
     
Class code Number of EEs
Estimated Payroll Rate
     
Class code Number of EEs
Estimated Payroll Rate
     
Class code Number of EEs
Estimated Payroll Rate
     
Class code Number of EEs
Estimated Payroll Rate
     
Class code Number of EEs
Estimated Payroll Rate
     
Policy Information
Current Carrier  
Renewal Date mm/dd/yy  
     
Security Question
What is Our Company's Name?  
   

 

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