'
State for this inquiry
'
and
'
Name of Employer
'
are required
.
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Classification Inquiry
*
= Required Fields
Enter the information below with a brief description of your inquiry.
Does your inquiry involve a particular employer?
Yes
No
State for this inquiry
-- Select State --
Pennsylvania
Delaware
*
Employer Information
Name of Employer:
*
Bureau File #:
*
Numeric Only
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In the event the Bureau needs to contact the employer either in person or via questionnaire, please provide the name and title of an individual who is qualified to speak authoritatively on the employer's operations.
Employer Contact:
Name:
*
Title:
*
Telephone Number:
*
xxx-xxx-xxxx
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Email Address:
*
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Your Information
Your Name:
*
Your Company's Name:
*
Your Company's Mailing Address:
*
Your Affiliation:
-- Select One --
Carrier Of Record
Carrier
Agent/Broker Of Record
Agent/Broker
Employer
Other
*
Your Email Address:
*
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Confirm Email Address:
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Optional
)
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**Separate multiple email addresses by a comma [
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Attachments:
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**If you want to attach a document to your inquiry, click on the Browse button and double-click the file(s) you want to include with your inquiry.**
Brief description of issue or question:
*