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*Prospect:
*Address:
*City State: *Zip:
*Contact: *Title
Phone: Fax: Email:
*ORG Type: *Nature of Business:
(100 chars max)
Year founded: Hours of Operation: *Start Up?:          Yes  No
*F.E.I.N. SIC Code: SUTA Rate
*Payroll Freq: Comp Coverage: Renewal Date:
Type of Medical Insurance requested: Risk finder attached: Yes  No *Currently with a PEO?: Yes  No
Reason for Leaving:           *Lead
           Source:

*COMPENSATION LINE ITEM DATA
COMP CODES JOB DESCRIPTION NO FT NO PT ANNUAL PAYROLL CURRENT COMP RATES

 

 
Totals:

WSE:

0

PAYROLL:

$0

 

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GENERAL INFORMATION

List any other locations including any outside the U.S.:

*A.  Are you engaged in any other type of business? Yes  No 
*B.  Are you a subsidiary of any other business? Yes  No 
*C.  Do you have any subsidiaries? Yes  No 
*D.  Do you use and/or have any volunteer, donated, part-time, or seasonal labor? Yes  No 
*E.  Do any employees travel and/or work out of state? Yes  No 
*F.  Is pre-employment testing required for alcohol/drugs, flexibility/dexterity/strength or hearing? Yes  No 
*G.  Do you have a formal written safety program in place? Yes  No 
*H.  Do you have a driver qualification program including MVR checks? Yes  No 
*I.  Do you use any sub-contractors? Yes  No 
*J.  Do you require certificates of insurance on all work you sublet? Yes  No 
*K.  Has your company ever had an EEOC suit lodged against it? Yes  No 
*L.  Do you own, operate or lease aircraft or watercraft? Yes  No 
*M.  Do you use any flammables, explosives, caustics, or radioactive materials? Yes  No 
*N.  Do operations involve the storage, treatment, discharge, application, disposal, or transport of hazardous materials? Yes  No 
*O.  Do you perform any work underground or above 15 feet? Yes  No 
*P.  Do you do any work on barges, vessels, docks, bridges or over water? Yes  No 
*Q.  Has your company ever been cited by OSHA, EPA or the State for violation of a law, regulation or ordinance? Yes  No 
*R.  Has any employee missed work for more that five(5) days during the last month due to injury or illness? Yes  No 
*S.  Do you have a medical benefit program for your employees? Yes  No 

Please give comments to any "yes" answers given for questions A thru S:

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