CLIENT INFORMATION. State: Non Profit PROPOSAL INFORMATION

Transcription

1 Sales Rep: XcelHR PEO Branch: CLIENT INFORMATION Company Name: Payroll Contact: Address: City: Phone: FEIN: SIC: Years in Business: Type: Sole Proprietor L.L.P. Corp State: Zip: Fax: Web site: NAICS: Description of Operation: S-Corp Partnership L.L.C. Other n Profit P.C. PROPOSAL INFORMATION Gross pay per Cycle: Number of ee s: Full time Part time PEO Name Pay Cycle: Using a PEO YES NO Proposal Due Date: Projected Start Date: SPECIAL PAYROLL INSTRUCTIONS Labor Distribution Job Costing EE Direct Deposit Certified Payroll? Client Billing: ACH Bankwire One payroll deposit List all owners and of ownership: Please Quote: ASO Date RFP Submitted: Need Proposal by: How many bound copies? Quote with Workers' Comp? Quote with Benefits? Employee Deductions: Health Premiums Garnishments Miscellaneous

2 Benefits Provider _ Plan Design PPO POS HMO Deductible $ Renewal Date Employer Contribution $ Life Provider If, Coverage Amount $ LTD Provider STD Provider Vision Provider Dental Provider Section 125 POP FSA Retirement Plan 401K Safe Harbor TPA Matching If, explain Pension Plan Description Other Retirement Benefits Supplemental Documentation Required: Last payroll register Most recent 1 month benefits billing for all benefit plans. (if benefits are to be quoted) Employee Census (if benefits are to be quoted) Benefit Summaries for all plans. (if benefits are to be quoted) Work Comp Dec Page and 3 years Loss History. Most recent State Unemployment Quarterly Report. If with a PEO, the first billing statement from January and the most recent billing statement. Copy of written PTO policy Comments: Comments:

3 Worker's Compensation subscriber profile Date: PEO Name: Section I: Subscriber Data (attach separate listing of all additional locations) Name: dba: Address: City State, Zip: ME/MN/MN Unemployment # (required to bind coverage): Key Contact: Safety Contact: Type of Business: Sole Prop. Description of Operations: Locations: Corp. n-profit (SIC Code: Number of locations: (Please enter each location address) Proposed Effective Date: Fed. Tax ID: NY/NJ Empl. #: NCCI ID: Years in Business: L.L.C. Phone: Fax: P.C. L.L.P Partnership ) / Number of States Location 1: Location 2: Location 3: Location 4: Location 5: Section II: Workers Compensation History (Attach current loss runs and explanations of all claims over $15,000) Year Carrier Policy # Premium Mod # of Claims Paid Losses O/S Reserves (Please attach loss runs, OSHA logs, current contract deck page and any additional information on the current program in effect.)

4 Section III: Employee Information (A separate payroll run or census may be provided. Provide complete information for each location) State Rate Number of EEs Est. Annual Payroll Duties UNDERWRITING QUESTIONS P.E.O. S ***Please explain all items answered yes, in detail, in the space provided below*** YES 1. Will any PEO employee work near or on the water? 2. Does client company have any operations involving exposure to chemicals, painting or hazardous materials? If yes to #2, above, will PEO s employees be exposed to such? 3. Will PEO employees perform any work below grade or above 6 feet in height? 4. Will PEO employees perform any work which may be subject to Jones Act, USL&H or FELA? 5. Is client company involved in any other type of business? If yes, will PEO employees be utilized for these operations? 6. Will PEO employees be exposed to performing electrical work, operating machinery, lifting exposures or use/operation of any mechanical equipment? 7. Are PEO employees subject to YOUR safety and drug-free programs? 8. Does client company have a written safety program in place? 9. Does client company have a drug-free workplace? 10. Does client company agree to PEO company s safety and drug-free policies by contract? 11. Are PEO employees subject to pre and post accident drug testing? 12. Will client company provide training for PEO employees for specific job duties and company specific safety procedures? 13. Are PEO employees subject to any group transportation? 14. Any PEO employees under 16 or over 60 years of age? 15. Will PEO employees be doing any driving? If so, why and radius? 16. Will PEO employees be working at a fixed jobsite? 17. Any PEO employees with physical handicaps? 18. Is there any travel exposure for PEO employees? 19. Will PEO employees be traveling out of State? 20. Are physicals required for (PEO employees) after offers of employment are made? 21. Has client company been inspected by OSHA in the past three years? 22. Was client company cited for any violations? If so, explain. 23. Was client company fined? If so, were corrective measures taken? 24. Do you have the ability to offer light-duty work for an injured PEO employee at this or another job-site? 25. Will PEO company or client company offer "full pay" during periods of disability or reduced work for an injured PEO employee? 26. Has client company had any workers compensation coverage declined, cancelled or non-renewed in the past three years? 27. Has client company had any workers compensation losses in the past three years? 28. What is client company s experience modification factor? Effective: 28. Are PEO employees offered health insurance? 29. Employee Annual turnover at client company Remarks Submitted by Date NO

5 WORKERS COMPENSATION LOSS AFFIDAVIT / STATEMENT OF NO LOSSES I, do hereby certify and swear as an owner and/or officer (Name of officer or owner) of that we have incurred injuries in the past (Company Name and dba, if applicable) thirty-six (36) month period. If losses have occurred please complete the following: Year # Claims Cost Incurred Company Name: Officer or Owner Signature: Position/Title: Dated: Fraud Statement Any person who knowingly and with intent to injure, defraud or deceive any insurer files, statement of claim, or an application containing false, incomplete or misleading information with the purposes of avoiding or reducing the amount of premiums for workers compensation or conceal information pertinent to the computation and application of an experience rating modification factor, is guilty of a felony of the third degree or otherwise punishable as provided under the law.

6 pr ice compar is ion sheet Comp Code 1 FICA FUTA SUTA Workers Comp HR Admin Benefits TOTAL THROUGH XCELHR Comp Code 2 Comp Code 3