| Client Company app |
| Agent Name |
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| Agent Email |
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| Client Name |
DBA |
Fed. Tax ID |
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| Physical Address |
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Contractors Lic#
If Applicable |
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| City |
State |
Zip |
NCCI ID |
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| Mailing Address |
City |
State |
Zip |
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| Owners Name |
Phone |
Years in Business |
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| Key Contact |
Safety Contact |
Fax |
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| Type of business |
Payroll Cycle |
Gross Wages
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Annual Revenue
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| Number of Employees: FT:
PT:
Seasonal:
Total:
Total W2:
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| Do you use a payroll service? |
Who? |
Annual Cost of Payroll |
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Yes
No |
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| Does Client have an HR Manager? |
Does Cliet have EPLI insurance? |
If Yes, cost: |
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Yes
No |
Yes
No |
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| Does Client have an Employee Handbook |
Does Client have Direct Deposit? |
If Yes how many using? |
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Yes
No |
Yes
No |
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| Sec 125 Plan |
401k Plan |
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Yes
No |
Yes
No |
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| 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) |
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Yes
No |
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| Dental Plan |
Does Client have an Employee Assistance Plan |
Number of Locations |
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Yes
No |
Yes
No |
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| Address of additional Locations: |
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Detailed Description of
Operations and Any large Claims |
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| List States Operating in:
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| Current Peo |
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| Current WC Carrier |
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Employee Information
(A separate Payroll run may be provided. Provide complete information for each location.) |
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| General Liability Expiration Date |
Upload Copy of GL Certificate |
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Workers’ Compensation History (Attach current loss runs and explanations of all claims over $15,000) |
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Upload WC Declaration page, loss runs, UCT-6 Tax rate info, payroll runs, pertinent health bills, Plan summaries, resumes, no loss letters or any other required or pertinent information by clicking on the browse buttons Bellow:
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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. |
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