- Fax Cover Sheet -

Request for proposal and additional information

Accu-Comp Fax to 203-458-1711

 

Your Company Name:______________________________________

Contact: _________________________________________________

Contact person’s Title: _____________________________________

Address: _________________________________________________

City: ____________________________________________________

Telephone Number: ________________________________________

Fax Number: _____________________________________________

E-Mail address: ___________________________________________

Website: _________________________________________________

Federal Employer ID Number: _______________________________

 

Approximate annual workers' compensation premium: $________________

Approximate number of employees: ____________

Has your company been part of a merger or acquisition in the last 4 years ___________

What is the best time to reach you to set up an appointment to discuss enlisting the services of Accu-Comp?

____________________________

* If possible please include a copy of your most recent NCCI Experience rating worksheet with your fax.

Please fax this questionnaire back to Accu-Comp at (203)458-1711