Get Started Here Business InformationLegal name*Doing Business As (DBA), if anyOwner's name First Last Contact name* First Last Contact title*Contact email* Contact phone*Website Headquarters address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country State of IncorporationYears in businessLegal structure (select one)01 Individual02 Partnership03 Corporation04 Association05 Limited Partnership06 Joint Venture07 Common Ownership08 Multiple Status09 Joint Employer10 Limited Liability Company11 Trust or Estate12 Executor or Trustee13 Limited Liability Partnership14 Government EntityFEIN (required)*NAICS Code (Optional)Are you a returning customer?*YesNoWorkers' Compensation InformationAre you a California Law Firm or a law firm with a presence in California?*YesNoDo you have 250 or more employees in one zip code?*YesNoDo you have 100 or more employees at one time (excluding shift work) in any of the following cities: Atlanta, Boston, Chicago, Dallas, Washington D.C., Los Angeles, New York, Philadelphia, San Diego, San Francisco, or Tampa?*YesNoSince you answered yes to the above question, please submit 5+ years and current YTD Workers Compensation Loss Runs and current Declaration Page or Billing Statement. Drop files here or Provide the name of your current Workers' Compensation Insurance CarrierPlease provide a copy of your current declaration. If you are with another PEO or are leasing employees, please provide a billing sheet with employees and workers. Drop files here or Describe the services your company provides and/or the products your company manufactures.Describe the physical processes involved in your business operations.Do you outsource any portion of your manufacturing or distribution?*YesNoSince you answered yes to the above question, please describe.Do you maintain a physical stock of your company's products?*YesNoDo your employees physically handle your company's products at any time?*YesNoSince you answered yes to the above question, please describe.Do employees perform demolition work or have exposure to hazardous materials, for example, asbestos?*YesNoSince you answered yes to the above question, please describe.Are you currently affected by exposure to the United States Longshoremen and Harbor Workers (USL&H) Act?*YesNoSince you answered yes to the above question, please provide examples (e.g. Employees work on water, docks, or barges).Are you currently affected by exposure to the Defense Base Act?*YesNoSince you answered yes to the above question, please provide examples (e.g. Employees work on US military bases).Are you currently affected by exposure to the Jones Act?*YesNoSince you answered yes to the above question, please provide examples (e.g. Employees who work on U.S. navigable waters).Do you own/operate/lease an airplane for business use?*YesNoDo you have any armed guard exposure?*YesNoSince you answered yes, are these your employees or contracted out through a security company?Do you have 1099 individuals (contract workers)?*YesNoFederal Employers Liability Act (FELA)?*YesNoSince you answered yes, please provide examples (e.g., Employees have exposure to railroad operations.)Medical InformationAre you a newly formed business or startup company?*YesNoDoes your group have over 100 full-time employees?*YesNoIs your group currently on a partially self-funded plan?*YesNoHow frequently do you prefer to pay your employees?*WeeklyBi-Weekly (every two weeks)Semi-MonthlyMonthlyIn addition to Medical Insurance, what other services do you want to offer your group?* Dental Vision None What percent of the premium do you want to fund for employees?100%90%80%50%What percent of the premium would you like to fund for dependents?*100%90%80%50%0%How much Life Insurance would you like to offer?*None$20,000$50,000$100,0001 x salary2 x salary3 x salaryHow much Long-Term Disability would you like to offer?*None50% of salary, 180 day waiting period60% of salary, 180 day waiting period67% of salary, 180 day waiting periodWould you also like to include Short-Term Disability?*YesNoPlease provide the effective date of the current medical plan. Date Format: MM slash DD slash YYYY Please provide the renewal date of the current medical plan. Date Format: MM slash DD slash YYYY Please list the medical carriers and/or PEOs you have had in the last 3 years.Number of current COBRA participantsDo not make inquiries to obtain the information below; please rely only on the information you currently possess.MedicalHIV Testing Prohibited: California law prohibits an HIV test from being required or used by a health insurance company or health care service plan as a condition of obtaining health coverage.Check all the conditions from the list below that you are aware of for any individual covered under the current plan, including COBRA participants, who had treatment, attention, or advice from a physician. Cancer Heart disease Stroke Kidney disease Diabetes (Type I or II) Liver disorder Spinal cord injury Premature infant(s) AIDS / HIV Intestinal disorders Tuberculosis or Other Respiratory disease Other major health impairment Number of employees with pregnancies (If known)List due dates (If available and known)Example: 05/23/2016, 06/01/2016,...Are you aware of any employees or dependents who are to be covered under the new medical plan who has incurred or had claims paid that totaled in excess of $10,000?*YesNoAre you aware of any employee or dependent who has been scheduled or advised to have extensive medical treatment, surgery, is confined, requires ongoing care, or has been advised to schedule a hospital visit?*YesNoSince you answered yes, please provide any information you can such as age of each person, gender, specific diagnosis, medical expenses the last 12 months, period of treatment, current prognosis/treatment plan, age at beginning of treatment, and if employee is actively at work.Are you aware of any employees or dependents who have a need for or are scheduled to have any organ transplant?*YesNoSince you answered yes, please provide any information you can such as age of each person, gender, specific diagnosis, medical expenses the last 12 months, period of treatment, current prognosis/treatment plan, age at beginning of treatment, and if employee is actively at work.Are any employees or dependents currently not active at work due to disabling illness or injury?*YesNoSince you answered yes, please provide any information you can such as age of each person, gender, specific diagnosis, medical expenses the last 12 months, period of treatment, current prognosis/treatment plan, age at beginning of treatment, and if employee is actively at work.Are any dependent children incapable of self-support because of physical or mental disability?*YesNoSince you answered yes, please provide any information you can such as age of each person, gender, specific diagnosis, medical expenses the last 12 months, period of treatment, current prognosis/treatment plan, age at beginning of treatment, and if employee is actively at work.Is there any person being treated for alcoholism or chemical dependency or been advised to seek treatment?*YesNoSince you answered yes, please provide any information you can such as age of each person, gender, specific diagnosis, medical expenses the last 12 months, period of treatment, current prognosis/treatment plan, age at beginning of treatment, and if employee is actively at work.