NEW CLIENT APPLICATION

Application Form

Date:
Business Development Rep:
Legal Business Name:
Type of Business:	Sole Proprietorship
	Corporation
	L.L.C.
	P.C.
	Partnership
Street Address:
City, State, Zip:
Secondary Location:
Client Contact:
Title:
Phone Number:
Fax Number:
# Years in Business:
Description of Business:
Current SUTA Rate:
Pay Frequency:	Weekly
	Bi-Weekly
	Semi-Monthly
	Monthly
Pay Type:	Commission
	Salary
	Hourly
# of Employees:
Gross Monthly Payroll $:
Current Payroll Method:	PEO
	Payroll Service
	In-house Staff
	Other (please describe)
Est. Current Monthly Payroll Processing Cost $:
		Renewal Date
Current Employee Offerings:	Medical
(check all that apply)	Dental
	Vision
	Life
	LTD/STD
	401K
	Employee Assistance
	Flex Spending
Current Workers Compensation Carrier:
Account #:
Classification Code 1:
# of Employees 1:
Classification Code 2:
# of Employees 2:
Current Documention:	Employee Handbook
	Safety Manual
Security Code: Please duplicate the following 6 character security code.