WC Approval Request

WORKER'S COMPENSATION APPROVAL & QUOTE REQUEST
Recruiting Firm Name*
Recruiter Name*
Recruiter E-mail*
Job Title*
Brief Description of Client Operations*
ex. Software Development Company
State*
Facility Type (i.e. office, hospital, warehouse, outpatient facility, nursing home)*

ClinicHospitalHome HealthRehab facilityNursing HomeWarehouseOfficeOther
Does this job description involve driving in a vehicle?

YESNO
Estimated Pay Rate
Estimated hours per week
Estimated length of assignment
Client company name that the contractor will be working
Client company address that the contractor will be working

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select from the below two choices to submit the job description
Upload Job Description File

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Additional Notes
By submitting this form, you are agreeing that the information provided above is accurate and true to the best of your abilities.*

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* Please allow from one to two business days to receive an email response.
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