WC Approval Request

WORKER'S COMPENSATION QUOTE REQUEST
Recruiting Firm Name *
Recruiter Name *
Recruiter E-mail *
Physical Work Location Type (i.e. office, hospital, warehouse, outpatient facility, nursing home) *
Does this job description involve driving in a vehicle?

YES NO
Job Title *
Pay Rate (must be an exact dollar amount) *
Estimated hours per week *
Estimated length of assignment *
State *
Client company name that the contractor will be working for
Client company address that the contractor will be working

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Brief Description of Client Operations *
ex. Software Development Company
Select from the below two choices to submit the job description
Upload Job Description File
Paste Job Description Link
Additional Notes
By submitting this form, you are agreeing that the information provided above is accurate and true to the best of your abilities. *

YES NO
* Please allow from one to two business days to receive an email response.
Enter the message as it's shown *
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