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Payroll Services Request Form

Company name: * Your name: * Email address: * Contact Phone: Information Concerning: PEO Services Payroll Only Payroll and Pay As You Go Comp Services Strategic Alliance Other Your Region National Central Florida Georgia Alabama Northeast Midwest Southwest California Other How do you wish us to contact you? Call me (please leave #) Call but only during work hours Call but only after hours email or call email only PLEASE DO NOT CALL! Other How did you hear about PAY-Surance HR? For Payroll quotes, please tell us a little about your business. What do you do? Your line of business? Business: How many employees do you have? What is your weekly payroll? (specify if not weekly) * required For other details, questions and comments please use the space below. For workers' comp rates it may be helpful to provide us with your experience mod and some loss history (if known.) Clicking the request button will generate an information request email. PAY-surance HR Corporate Headquarters: 1802 N. Alafaya Trail Orlando, FL 32826 (800) 788-8343 (in Orlando: (407) 992-4420)