workers’ e-comp – payroll and workers’ compensation ... · (f heartland ovation payroll ....

Company Name

Address

City State Zip

Phone Fax

Contact Name email

Years in Business FEIN

Entity Type (Corp/Partnership/Individual)

Type of Business/Description of Operations

Current Workers Comp Insurance Carrier

Renewal Date Payroll Client #

Payroll Rep Phone Number/email

Number of Employees (Full Time/Part Time)

Any losses during the last 5 years?

Class Code Estimated Annual Payroll

Class Code Estimated Annual Payroll

Payroll Frequency 1st Check Date

25% Minimum No Deposit/No Down Payment

Estimated, based on projected payroll(usually underestimated

Monthly/quarterly audit reports to complete

Year-end on site or phone audit, documentation required, additional premium due or refund

Deposit/Down Payment

Premium

Reports

Audit

multiple carriers, expertise and exceptional service all in one place.

www.ecomp.us888-493-2667

License #OC41366

audit adjustment and no additional paperwork (unless state or carrier mandated)

E-COMP – Payroll and Workers’ Compensation In One Integrated, Pay-As-You-Go Program

workers’compensation

Traditional Workers' Comp.(The Old Way)

Pay-As-You-Go Workers' Comp.(The New Way)

Fax to 888-738-9097or

E-mail to submissions@ecomp.us