Request for Proposal

Thank you for your interest in WorkSmart Systems! We know you have many options when choosing a vendor and we are happy to prepare a proposal for you. Please fill out the form below and we will contact you for the next steps in the process or if any other information is needed. If you have any questions, please call 317-585-7870.


In addition, we will be requesting the following:
  • 1) Average gross payroll per cycle and number of employees associated with each worker' compensations code, including current rates.
  • Example
    Clerical
    Code - 8810
    $1,000
    2 Employees
    Sales
    Code - 8742
    $2,000
    3 Employees
    Manufacturing
    Code - 4484
    $3,000
    5 Employees
  • 2) Copy of workers' compensation policy declaration page or the page in policy that lists worker's compensation codes and experience modification.
  • 3) Copy of medical insurance plan premiums and summaries for past two years.
The following items will be emailed to you to complete online:
  • 1) Completed Group Health Questionnaire (GHQ)
  • 2) Each benefit eligible employee must complete the Personal Health Information Qestionnaire (PHQ) (even if they are waiving coverage).
    This includes any former employees that have elected COBRA continuation in your group medical plan.
We'll also be requesting:
  • 1) Average gross payroll per cycle and number of employees associated with each worker' compensations code, including current rates.
  • Example
    Clerical
    Code - 8810
    $1,000
    2 Employees
    Sales
    Code - 8742
    $2,000
    3 Employees
    Manufacturing
    Code - 4484
    $3,000
    5 Employees
  • 2) Copy of workers' compensation policy declaration page or the page in policy that lists worker's compensation codes and experience modification.
  • 3) Copy of workers' compensation loss runs for the past three years or a short letter indicating no workers' compensation losses for the past three years.
  • 4) Copy of medical insurance plan premiums and summaries for past two years.
  • 5) Please obtain claims information from your current medical insurance carrier per Indiana Bulletin 174 requirements.
The following items will be emailed to you to complete online:
  • 1) Completed Group Health Questionnaire (GHQ)
  • 2) Electronically completed census spreadsheet.
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