Workers Compensation Survey
		Complete the following survey and a ProLogi.com representative will contact you within one working day.
Company Information
Company Name
Associate
Title
Address
Address 2
City, State, Zip
Telephone
Facsimile Number
eMail Address
Workers Comp Information
WC Bureau ID Number
FEIN Number
DOT Number
MC Number
Fleet Category		Motor Carrier Private
Principal Officer or Owner
Insurance Contact
Telephone
Facsimile Number
eMail Address
Locations in Each State
Current Experience Modification
Number of Missed Work Days Per Calendar Year
Type of Business
Are Medical Benefits Provided?		yes no
Personnel Information
Number of Part Time Employees
Number of Full Time Employees
Number of Seasonal Employees
Number of Temporary Employees
Number of Manager/Supervisors
Required Experience
Minimum Age
Maximum Age
Physicals Required
Are Employees Union?		yes no
Number of W-2's Issued Last Year
Percent of Turnover
Annual Payroll by Classcode
Class code		Payroll
Class code		Payroll
Current Insurance Carrier
Policy Number
Expiration Date