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Workers Comp Form
Company Legal Name:
DBA:
Address:
Phone:
Fax:
Website:
Federal ID:
Type of Business:
Years in business:
Experience Modification Factor:


Owner 1:   Owner 2:
Percent ownership:   Percent ownership:
Owner exempt:   Owner exempt:
Owner 3:   Owner 4:
Percent ownership:   Percent ownership:
Owner exempt:   Owner exempt:

Contact 1: Contact 2:
Title: Title:
Phone: Phone:
Cell Phone: Cell Phone:
Email: Email:

Pay Frequency:
Pay Ending Day:
Pay Day:
Comments:

       

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Registered Representative and Financial Advisor of Park Avenue Securities LLC (PAS), (920 Second Avenue South, Suite 1100, Minneapolis, MN 55402) Securities products/services and advisory services are offered through PAS, a registered broker-dealer and investment advisor, (612-746-2200) Financial Representative, The Guardian Life Insurance Company of America (Guardian), New York, NY. PAS is an indirect, wholly owned subsidiary of Guardian. Foster Klima & Company, Inc. is not an affiliate or subsidiary of PAS or Guardian.

PAS is a member FINRA, SIPC.

The Living Balance Sheet® and the Living Balance Sheet® Logo are registered service marks of The Guardian Life Insurance Company of America (Guardian), New York, NY. The graphics and text used herein are the exclusive property of Guardian and protected under U.S. and International copyright laws. © Copyright 2005-2014, The Guardian Life Insurance Company of America.

The Guardian Life Insurance Company of America (Guardian), New York, NY, its subsidiaries, agents or employees do not give tax or legal advice. You should consult your tax or legal advisor regarding your individual situation.