Complete and submit the following form to obtain a quote for our unemployment insurance tax reimbursing services. We will respond to your request immediately.  
 
 
 
 
Organization Name*
 
 
 
 
First Name*
 
 
Last Name*
 
 
 
Job Title*
 
 
 
 
City*
 
 
State*
 
 
 
Email*
 
 
Work Phone*
 
 
 
State ID#
 
 
 
 
   
 
 
Payroll History
 
 
 
 
Total Gross Annual Payroll (Q3/2017 - Q2/2018)
 
 
 
 
Total SUI Taxable Payroll (Q3/2017 - Q2/2018)
 
 
 
 
 
 
 
Current Unemployment Program Method
 
 
 
 
How does your organization currently pay for unemployment?*
 
 
 
 
Current UI tax rate % (if applicable)
 
 
 
 
 
 
 
Unemployment Benefits History
 
 
 
 
Please indicate your organization's total amount paid in claims for the following years. When listing current year indicate claims paid to date.  
 
 
 
 
2016 Claims Paid
 
 
2017 Claims Paid
 
 
 
2018 Claims Paid
 
 
 
 
 
 
 
Are you anticipating any funding changes in the next 24 months?*
 
 
 
 
Are you anticipating any layoffs in the next 24 months?*
 
 
 
 
 
 
 
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