Quick Quote - Staff BrokersStaff Brokers

Fill out the information below to receive a quote. The quote will be sent to the email you provide, or call toll-free 1.877.416.0668 to speak to a representative. A Staff Brokers Consultant will contact you within 24 business hours to review the status of your quote and help you create a customized PEO solution that meets your company’s specific needs.

Company Info

Business Legal Name (required)

DBA:

FEIN:

Owner Name:

Contact Name:

Phone Number:

Best Time to Call:

Email Address:

Years in Business:

Prospect's Current Experience MOD:

Detailed Description of Operations

Workers' Comp Information (Required): Total Gross Annual Payroll must be greater than $26,000

State	Code	# of Employees	Gross Annual Payroll

Loss Information

Please submit available losses or complete the chart below.

Check if loss history is unknown

Policy Year	# of Claims	Total Incurred

Upload a Document (Optional)

(Accord Apps, Loss Runs, Supplemental Apps, etc.)