Info Request

Main Company Info

Company Name/DBA*

FEIN*

Entity Type

Years in Business

Website

Description of Business

SIC Code*

NAICS Code

Name

First Last

TItle

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Addresses of Additional Locations

Total # of Locations

States of Operation

Location 2

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location 3

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location 4

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location 5

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

# of Full Time Employees

# of Part Time Employees

Human Resources Specifics

Payroll Frequency*

Pay Period Start Day

Workers Comp Rate

(Expressed as $0.00 per $1000 of Payroll)

Workers Comp Renewal Date

Workers Comp Current Limits

State Unemployment Tax Rate

(Expressed as $0.00 per $100 of Payroll)

Additional Info

Any employee related litigation, investigations, or charges in the past 5 years?*

Yes
No

If yes please provide details:

Are there any potential pr pending claims against the company or owners?*

Yes
No

If yes please provide details:

Any tax liens or bankruptcy filings in the past 5 years?*

Yes
No

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Momentum Info Request Form

Step 1 of 2

Main Company Info

Addresses of Additional Locations

Human Resources Specifics

Additional Info

Workers Compensation Info Request

- Workers Comp - Partners, Officers, Relatives to be included or excluded

- Provide Carrier and Loss History Info - Past 5 yrs

- Workers Comp - General Info