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["PEO Brokers Group"]
["COMPANY INFORMATION FORM                                                                                                                                                                                                        (Please answer all questions fully or note NA)"]
["Legal Company Name",null,null,null,null,null,"Years in Business ",null,"Federal ID# include copy of IRS EIN Form",null,null,"Date "]
["DBA",null,null,null,null,null,"Owner",null,null,null,null,"Ownership %"]
["Company Address",null,null,null,null,null,"City",null,null,null,"State/Zip"]
["Phone",null,null,null,"Ext",null,"Fax",null,null,"Mobile "]
["Contact ",null,null,null,"Title",null,null,"Email"]
["Contact 2",null,null,null,"Title",null,null,"Email"]
["Web",null,null,null,null,null,null,"States of Operation"]
["Business Type include copy Business Registration","C Corp","S Corp","LLC","Sole Proprietor","Total Employees",null,"Total Employees by State"]
[null,null,null,null,null,"Pay Frequency","By State","W, BW, SM, or MO"]
["Other Locations Addesses:"]
[]
["Description of Operations"]
["Current PEO or Payroll Customer – Name & Address",null,null,null,null,null,null,null,null,null,"Current Admin Fee",null,"Attach a Copy of Current Invoice"]
["Workers’ Compensation Information - Include current year's policy dec page"]
["Work Comp Modifier","YR","Workers’ Compensation Carrier (must include 3 years loss runs to date of application)",null,null,null,null,"Policy Expiration Date","Deposit Amount",null,"Premium Amount",null,"Annual or Monthly"]
[]
[]
[]
[]
["Payroll by Work Comp Code or Description - (Additional info? - attach a separate sheet)"]
["The information by comp code may be found on your WC Policy - you may attach a YTD Payroll Summary by Employee for wage information.  We will need each employee's workers compensation classification (clerical, sales, warehouse, etc.) and number of employees by code.  Email Information with form."]
["Work Comp Code i.e.8810","Description",null,null,"Current Rate","$ Amt of Gross Payroll Per Class",null,"Freq/W, BW, etc",null,"State","# of EE’s","FT","PT"]
[]
[]
[]
[]
[]
[]
[]
[null,"Totals",null,null,null,{"$f":"SUM(F25:G31)","v":0},null,null,null,null,{"$f":"SUM(K25:K31)","v":0},{"$f":"SUM(L25:L31)","v":0},{"$f":"SUM(M25:M31)","v":0}]
["To expedite the information process and in order to clearly define and quote your company's needs, we must have your payroll information by work comp code with number of employees per code. (include a copy of your last annual payroll report and YTD payroll report by WC Code along with your quarterly 941's) See Section 2 for required underwriting info."]
[]
[]
["Workers’ Compensation Losses - ATTACH last 3 years of Current Valued Loss Runs (must be valued within 30-45 days of date of application) "]
["Year",null,"Total Incurred Loss Dollar Amount",null,null,"Carrier"]
[]
[]
[]
[]
["The following is additional information that is helpful in determining the best fit for your company."]
["CLIENT PREFERENCES"]
["Section 1"]
[null,"Payroll Types",null,null,null,null,null,null,null,null,"Required","Interested","Not Interested"]
[1,"Commission"]
[2,"Bonuses"]
[3,"Vacation"]
[4,"Sick Time"]
[5,"Jury Duty"]
[6,"Voting Time"]
[7,"Paid Time Off"]
[8,"Expense reporting/reimbursement"]
[null,"Vacation & Sick Time Tracking",null,null,null,null,null,null,null,null,"YES","NO","Interested"]
[9,"Tracking of Vacation and sick time usage and accruals"]
[10,"Carry over annual vacation and sick time"]
[11,"Vacation, sick, jury duty, etc – visible on check"]
[12,"Available accrued time off on check"]
[null,"Time & Attendance Systems",null,null,null,null,null,null,null,null,"YES","NO","Interested"]
[13,"Currently have Company owned Time Clocks"]
[14,"Currently using PEO Time Clocks"]
[15,"Interested in Time & Attendance System (upgrade or new)"]
[16,"Fax in Time/Payroll"]
[17,"Email Time/Payroll"]
[18,"Transfer from Time System/Custom bridge needed - describe:"]
[19,"Type of System"]
[null,"Labor & Payroll Reports",null,null,null,null,null,null,null,null,"Required","Interested","Not Interested"]
[20,"Labor Distribution Reports by department or job"]
[21,"Custom import data reporting "]
[22,"Certified Payroll Reports"]
[null,"Internet Requirements",null,null,null,null,null,null,null,null,"Required","Interested","Not Interested"]
[23,"Internet payroll capabilities"]
[24,"Employee access to employee only files"]
[25,"Employee/Employer reporting hours "]
[26,"Benefit enrollment for employees"]
[27,"Payroll report access"]
[28,"Custom report access"]
[null,"Delivery of Payroll",null,null,null,null,null,null,null,null,"Required","Interested","Not Interested"]
[29,"Direct Deposit "]
[30,"Direct Pay Cards"]
[31,"Mail – Certified"]
[32,"Express (FedEX, DHL, UPS, Lonestar, etc)"]
[null,"Human Resources & Unemployment Assistance",null,null,null,null,null,null,null,null,"Required","Interested","Not Interested"]
[33,"Employee Handbooks/ Company Policy manual assistance"]
[34,"Hiring Assistance"]
[35,"HR Training"]
[36,"Bilingual "]
[37,"If required - Language"]
[38,"Unemployment Assistance"]
[39,"Outplacement services"]
[]
["Section 2 ","  Underwriting Information Required",null,null,null,null,null,null,null,"Yes","No","Give a description of Yes answers on page 4 in blank section if extra space is needed"]
[1,"Does applicant own, operate or lease aircraft/watercraft?"]
[null,"Type & Use"]
[2,"Do / Have past, present, or discontinued operations involve(d) storing, treating, discharging, applying, disposing or transporting of hazardous material?  (e.g. landfills, wastes, fuel tanks, etc)"]
[null,"If Yes – type of work/materials"]
[3,"Any Work performed underground or above 15 feet? "]
[4,"Any Work performed on barges vessels, docks, bridge over water?"]
[5,"Is applicant engaged in any other type of business? Details of business(es)."]
[6,"Are subcontractors used?",null,null,null,null,null,"% of Work"]
[7,"Any subcontractors working without certificates of insurance? (If yes include payroll for this work in the Work Comp Section.)"]
[8,"Safety - SEE Below *****Safety Programs"]
[9,"Any group transportation provided by company?"]
[10,"Any employees under 16 or over 60 years of age?"]
[11,"Any Seasonal employees?"]
[12,"Any volunteer or donated Labor (if Yes please describe below)"]
[]
[13,"Any employees with Physical Handicaps?"]
[14,"Do Employees travel out of state? (if yes, indicate the state(s) and travel frequency)"]
[null,"States"]
[15,"Are athletic teams sponsored?"]
[16,"Are physicals required after offers of employment are made?"]
[17,"Any other insurance with insurer?"]
[18,"Any prior Coverage declined/non-renewed/cancelled in the last 3 years? (Missouri NA)"]
[19,"Are health insurance plans provided?"]
[20,"Do employees perform work for other businesses or subsidiaries?"]
[21,"Do you lease employees to or from other employers?"]
[22,"Do employees predominantly work from home?  If yes # of employees?",null,null,null,null,null,null,null,null,null,"# of EES"]
[23,"Any tax liens or bankruptcy within the last 5 years (business) If yes specify.",null,null,null,null,null,null,null,null,null,"Year/type"]
[24,"Any undisputed and unpaid workers compensation premium due? Amount/explain",null,null,null,null,null,null,null,null,null,"Amount"]
[null,"Explanation"]
["Section 3"]
["*****","8. Safety Programs",null,null,null,null,null,null,null,"Yes","No"]
["i","Formal Safety Program in use"]
[" ","If Yes - describe"]
["ii","OSHA Programs in use"]
[null,"If Yes - names"]
["iii","Any fatalities – last 3 years"]
[null,"If Yes - describe"]
["iv","Safety awards"]
[null,"If Yes - name"]
["v","Safety handbooks"]
[null,"If Yes - describe"]
["vi","Safety inspections"]
[null,"If Yes – describe & by whom"]
["vii","Safety manager onsite",null,null,null,"Name"]
[null,"If Yes – describe duties"]
[null,"   "]
["viii","Regular Safety training classes for workforce"]
[null,"Describe: "]
["Section 4","Benefits"]
["The following is regarding benefits, retirement plans, etc. (If needing a quote, please provide a census and previous carrier info.)"]
[]
[null,"Type",null,null,null,"Option",null,null,null,"Yes","No","Deductible"]
["A","Major Medical",null,null,null,"Select Applicable",null,null,null,null,null,"Yes","No"]
[null,null,null,null,null,"HMO",null,"PPO"]
["B","Dental"]
["C","Vision"]
["D","Portion Paid by Company"]
["E","Supplemental Products"]
["F","Flex Accounts"]
["G","401(k)"]
["H","Simple IRA"]
[]
["Use these blanks to describe any YES Answers in the underwriting section & note question number. "]