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Request for Proposal

Company Information:
	* = required field
*Company Name:
*Address:
*City:
*State / Province / Region:
*Zip / Postal Code:
*Contact Name:
Title:
*Phone:
Fax:
*Email:
Business Description:
*Number of Full-time Employees:
Number of Part-time Employees:
*Payroll Cycles Per Year:
Average Gross Pay Per Cycle:

Company Benefits Information:
Do you currently offer medical benefits for your employees?	Yes No
If yes, when is your renewal date?	(Format: mm/dd/yy)
What is your medical deductible?
Do you provide dental?	Yes No
Do you provide vision?	Yes No
Do you provide STD & LTD?	Yes No
Do you provide a retirement plan?	Yes No
If yes, please specify:
Do you offer a Cafeteria Plan / Section 125?	Yes No
Does your Cafeteria Plan / Section 125 offer Flexible Spending?	Yes No
Does your Cafeteria Plan / Section 125 offer Dependent Care Reimbursement?	Yes No
As the employer, do you make a contribution to the cost of the employee benefits?	Yes No
If yes, please explain:

Worker's Compensation Insurance Policy Information:

If yes, when is your renewal date?

(Format: mm/dd/yy)

Experience Modification Rate:

Classifications	Comp Code	Annual Payroll	# Employees
Example	4484	$3,000	5

Number of Claims over the Last Five Years:

Unemployment Information:

Current State Unemployment Tax Rate for each state you have employees:

Number of Claims over the Last Five Years:

Accountant Information:
Do you have a Certified Public Accountant?	Yes No
Name:

How did you find WorkSmart Systems?
*Referral Source:

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