Instructions for submitting
Client Company Survey

Please complete the Client Company Survey via:

• Online Form
• Download a MS Word version of the form.

1. Please complete the attached Client Company Survey and provide the applicable documentation requested below
2. Make sure you provide an excellent detailed description of operations and the chart showing the actual payroll and number of employees by WC code. If the chart does not have enough boxes please provide an attachment showing this information.

* The chart with the payroll breakdown is not necessary if WC is to be carved out. In this case we just need the total annualized payroll.    

We also must have the following support documentation:

1. We must have a Workers Compensation Declaration and Information page. (This is the page of the policy that shows the estimated payroll by WC code, Modifier, any discounts and premium)
   
   1. A current UCT-6 or similar or similar form (state specific) showing your state tax rate for each state you have employees in.
   2. If with a PEO then it is mandatory that we get a PEO billing report and payroll report in lieu of the items above
   3. * If you are a multi state operation then please provide a breakout of the number of employees and payroll by WC code for each state.
      
2. At least three years of workers compensation loss runs (four is always better but three will suffice with most PEO’s) or for the entire time in business from carrier(s) or PEO's or both.
   
1. If no prior WC we need a letter on letterhead stating that you have had no prior WC or WC losses
2. A good description of any large WC claims (If any) also stating what has been done to minimize potential of reoccurrence (if anything)
   
   * Items 1 and 2 A and 2B are not necessary if WC is going to be carved out.
   
3. If in business for less than three years we need a resume of the principals

If Medical Insurance is required we need the following:

The completed medical questionnaire and Census (must have date of birth, sex and zip code for each employee as well as the coverage desired whether

1  Employee
2  Employee and Spouse
3  Employee and Children
4  Full family
5  Declined with verifiable coverage elsewhere
6  Declined with no coverage
7  Part time
8  Not eligible yet due to time in service

Also please let us know on our client survey form how much your client company contributes towards health plans

• A copy of your current health bill from your PEO.
• A plan description of your current benefits

Submit this form online, or fax to PEO Source at (407) 898-6419 .