PEO Source
Orlando - Corporate
Phone (954) 294-1432
Fax (561) 828-6128

South Florida
Phone (954) 294-1432
Fax (561) 828-6128

Northeast
Phone (917) 941-0824
Fax (561) 828-6128




Client Company Survey

Client name DBA Fed. Tax ID
Physical Address   Contractors Lic#
If Applicable
City State zip ncci id
Mailing Address City state zip
Owners Name Phone Years in business
Key contact safety Contact Fax
Type of business Payroll cycle  
 
Number of Employees: FT: pT: Seasonal: total: total w2:
Do you use a payroll service? Who? Annual Cost of Payroll
Yes No
Does Client have an HR Manager? Does Cliet have EPLI insurance? If Yes, Cost:
Yes No Yes No
Does Client have an Employee Handbook Does Client have direct Deposit?  If Yes how many using?
Yes No Yes No
Sec 125 Plan 401k Plan  
Yes No Yes No  
Does client plan on Utilizing PEO health Plan ? If so how much- or what % - do you pay for single, employee or families? (IE.  50 % of single, 50% of family, or a different level)
Yes No  
Dental Plan Does Client have an Employee Assistance Plan Number of locations
Yes No Yes No
Address of additional Locations:
 
 

Detailed Description  Of operations and Any large Claims

List States operating in:
current Peo
current WC Carrier
Employee Information
(A separate Payroll run may be provided. Provide complete information for each location.)
Hazard Group
Class Code
Rate
Number of EEs
Duties
Annual Payroll
General Liability Expiration Date Upload Copy of GL Certificate  

Workers’ Compensation History (Attach current loss runs and explanations of all claims over $15,000)
year
carrier
Policy #
premium
Mod
# of Claims

Paid
losses

OS
Reserves

I attest that the claims information is, to the best of my knowledge, correct.  I also attest that no outstanding premiums are owed to any other Professional Employer Organization.           

   

PEO Source - Corporate 1120 Portland Avenue, Suite 3 • Orlando, Florida 32803 • (954) 294-1432 • Fax (561) 828-6128 •
www.PEO-Source.com • PEO Source • Providing Coverage Country-Wide

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