Forms - hrresourceinc.com

Request For Information

* required fields

Name of Business*

Address *

City *

State *

Zip Code *

Industry

SIC Code (if known)

# of years in business

Total # of employees *

E-mail *

Phone

Contact Name *

Do you currently have a group plan in place? Yes No

If Yes, what Insurance Company?
Policy #
Renewal Date

Do you currently have a broker? Yes No

If you have 5 employees or less, some carriers will require you provide tax information showing proof of business.
Please provide the following tax forms based on your type of business:

Sole Proprietorship	IRS Form 1040 and Schedule C or F
Partnership	IRS Form 1065
Corporation	IRS Form 1120
S Corporation	IRS Form 1120S or 2553
LLC or LLP	IRS Form 1040 and Schedule C or F, 1065 or 1120

Most recent Washington State Employer’s Quarterly Report for Industrial Insurance (form #212-055);

Most recent Washington State Employment Security Quarterly Wage Detail Report (form # EMS 5208 B).

If you have been in business for less than a year and have not filed any of the above forms, we will not be able to obtain quotes on your behalf.

Please download the forms below and complete to the best of your knowledge.
Save the forms to your computer and then attach them.

Search Letter Census Risk Questionnaire

Attachment 1 (Search Letter):

Attachment 2 (Census):

Attachment 3 (Risk Questionnaire):