Business Name
Business Type
Address A	Street Address
	City State Zip Code
Phone/Fax	- -
Contact Name A	First Name Middle Name Last Name
Contact Phone A	- (If different than business phone)
Email Address
# of employees ?
Current vendor ?
Best Time To Call
Accountant
How did you hear about us?	Mailer Email Accountant Referral Former Client Current Client Referral Friend Other Salesperson Phone Call
How are your employees paid ? Hourly Salary Both How often are your employees paid ? Weekly (52) Semi-Monthly (24) Bi-Weekly (26) Monthly (12) Are you interested in Pay-As-You-Go Workers Comp Information ? Yes Renewal Date   No Are you interested in Insurance Information ? Yes Renewal Date   No