Worker's Comp: Add a new location

Please describe the change you would like to make

Business Name:

What date would you like this change to be effective: *

Please provide information about the new location

Street address: *

City, state, zip code: *

Phone number: *

Is this location replacing an existing location: *

Yes

Click here if you answered "yes" to the above question

Address of location being replaced:

Should all payroll be transferred from the old location to this new location:

Yes

Click here if you answered "no" to the above question

Please provide information about the employees and payroll at this location

4-digit classification code:

Description of classification code:

How many full-time employees do you have in this classification:

How many part-time employees do you have in this classification:

What is the estimated annual payroll that you will have for this classification:

Comments or additional information:

Customer name or code:

Thanks for providing this information . If we need to contact you for additional information, we will send you a message through the secure Message Center. You can view a copy of this request by clicking on File Cabinet. You will receive an email confirming this request made on Sunday, February 5, 2012 - 9:02pm.

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Worker's Comp: Add a new location

Please describe the change you would like to make

Please provide information about the new location

Please provide information about the employees and payroll at this location