Worker's Comp: Add a new location

Please describe the change you would like to make

Business Name:

What date would you like this change to be effective: *

Please provide information about the new location

Street address: *

City, state, zip code: *

Phone number: *

Is this location replacing an existing location: *

Yes

Click here if you answered "yes" to the above question

Address of location being replaced:

Should all payroll be transferred from the old location to this new location:

Yes

Click here if you answered "no" to the above question

Please provide information about the employees and payroll at this location

4-digit classification code:

Description of classification code:

How many full-time employees do you have in this classification:

How many part-time employees do you have in this classification:

What is the estimated annual payroll that you will have for this classification:

Comments or additional information:

Customer name or code:

Thanks for providing this information . If we need to contact you for additional information, we will send you a message through the secure Message Center. You can view a copy of this request by clicking on File Cabinet. You will receive an email confirming this request made on Monday, February 6, 2012 - 9:42pm.

By clicking the Submit Button you are agreeing to the Terms Conditions of doing business with our agency via the Internet.
Click here to view the Terms & Conditions.

Umpqua Insurance

Suckerfish menu

Worker's Comp: Add a new location

Please describe the change you would like to make

Please provide information about the new location

Please provide information about the employees and payroll at this location

User login