Compensation Solutions The Human Resources PEOple™
Take care of
your most important asset. . .
your employees.
Company
Name
Type of
Business
Address
Contact
Person
Title
Phone
Fax
Federal
ID #
Years
in
Business
E-Mail
Address
Website
# Full-Time
Employees
#
Part-Time
Employees
Any Worksite locations outside of
NY or NJ or CT or PA?
Yes No
If Yes, what states and number of employees per state
(Indicate full-time and part-time)
Payroll
Company
Payroll
Costs
Gross Payroll per Pay
Period
or
Annually
Pay Period:
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Amount of Gross Payroll that are Guaranteed Bonus
payments...............................................................
Amount of Gross Payroll that are Non-Guaranteed
Bonus payments.....................................................
401k
Vendor
Approx
$ Assets
Current PEO
Current
PEO Fee
Do you currently provide
health benefits to your employees? Yes
No
Health
Carrier
Health
Renewal Date
Number
of Employees (Full-Time) on Health................
Do you sponsor all/part of Employee's Cost?
Yes
No
Employer Contribution
%
....................or
$
Monthly Health Rates
..............
Sin .............
..............
PC ............
....................HW
...................Fam
Does your Company currently
offer?
Section 125 'Pre-Tax' Cafeteria Plan?
Yes
No
Flex-Spending & Dependent Care Plan?
Yes
No
Dental Insurance?
Yes
No
Group Longterm Disability(LTD)?
Yes
No
Employee Assistance Program?
Yes
No
Group
Life?
Yes
No
Group Life Amount
$
Vision Plan?
Yes
No
Employee Handbooks?
Yes
No
Current State Unemployment Tax Rate (SUI)...............
Number of Unemployment Claims In The Past 12
Months....................................................................
WC Carrier
Premium
Number of Workers Compensation Claims
(Past 3 Years).........................................................
Workers'
Comp Mod
Limits
$
Estimated
Costs of Personnel Administration as a percent of gross wages?
2% 3 %
4% 5%
6%
How did you hear about Compensation
Solutions?
or
type source below:
- Referral
Contact
- Network
Event
- Mailer
- Internet
- Other
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thorough as possible, it will aid us in helping to create the best solution
for your company.
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after submitting this form.
