Estimated Annual Savings: Workers' Compensation for Long-Term Care Facilites

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Company Information

Company Name

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FEIN

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First Name

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Last Name

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Street

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City

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State

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ZIP / Postal Code

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Primary Phone Number

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E-Mail Address

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Facility/Provider Type

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Estimated Annual Employee Payroll / Class Code 8829

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Estimated Annual Employee Payroll / Class Code: 9070

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Current XMod Factor

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Number of Licensed Beds

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Expiring Premium

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Number of Facilities

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Copy of Your Insurance Declaration Page

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