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Classification Inquiry
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= Required Fields
Enter the information below with a brief description of your inquiry.
Does your inquiry involve a particular employer?
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State for this inquiry
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Pennsylvania
Delaware
Employer Information
Name of Employer:
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Bureau File #:
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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:
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Title:
*
Telephone Number:
*
xxx-xxx-xxxx
Email Address:
*
Your Information
Your Name:
*
Your Company's Name:
*
Your Company's Mailing Address:
*
Your Affiliation:
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Carrier Of Record
Carrier
Agent/Broker Of Record
Agent/Broker
Employer
Other
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Your Email Address:
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Confirm Email Address:
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Attachments:
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Brief description of issue or question:
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