How did you hear about us?
If other, please list
Company Name *
 Contact Name*
Main Physical Address *
 Title
City *
 Phone # *
ext.
State *
 Zip Code*
Federal ID #
E-mail Address*
Total Number of Employees:
Full Time: Part Time:
   

PAYROLL INFORMATION

Payroll Frequency: Weekly Bi-Weekly Semi-Monthly Monthly
Does your company have a payroll service? Yes No
     If yes, what is the estimated annual cost? $
Do they provide any services other than payroll? Yes No

Please Provide The Following Documentation:
  • Copy of latest two 941 Quarterly Federal Tax Forms
  • Copy of latest SUTA return (include employee listing page)

GENERAL BUSINESS INFORMATION

Type of Business
Year Founded Hours of operation
  Short Description of Operations...
 
Yes No Do you have offices in multiple states or countries?
Yes No Are you engaged in any other type of business?
Yes No Do you have any subsidiaries?
Yes No Is your business a subsidiary?
Yes No Do you utilize subcontractors?
Yes No Do you require certificates of insurance on all work you sublet?
Yes No Do you own, operate or lease aircraft or watercraft?
Yes No Do you use any flammables, explosives, caustics or radioactive materials?
Yes No Do operations involve the storage, treatment, discharge, application, disposal or transport of hazardous materials?
Yes No Do you perform any work underground or above 15 feet?
Yes No Do you do any work on barges, vessels, docks, bridges or over water?
Yes No Has your company ever been cited by OSHA, EPA or the State for violation of a law, regulation, or ordinance?

If you answered yes to any of these, please provide additional information for the specific question...

BENEFIT INFORMATION

Do you have a medical, dental, or vision plan? Yes No
If yes, please list the type(s) of plan and the providers(s):
Please provide: Copy of current plan summaries & rates (% Company paid of each)
Do you have a Section 125 plan? Yes No
Do you have a Retirement plan? Yes No

What is the annual cost to administer each plan?
Medical $ Dental $ Vision $ Section125 Plan $ Retirement Plan $

EMPLOYEE AND WORKER'S COMPENSATION INFORMATION

Please Provide The Following Documentation:
  • Copy of current pricing & coverage limits page(s) (also called Declaration Pages)
  • Copy of last two (3) years loss runs (if no claims or losses during that time, please provide a statement to that effect on your company letterhead)
(Below) Please list current combined annual payroll by WC Code with the # FT and PT Employees
Code
Job Description
# of FT
# of PT
Payroll
Current Rates
Code
Job Description
# of FT
# of PT
Payroll
Current Rates
Code
Job Description
# of FT
# of PT
Payroll
Current Rates
Code
Job Description
# of FT
# of PT
Payroll
Current Rates
Code
Job Description
# of FT
# of PT
Payroll
Current Rates

When is the Renewal Date for Workers Compensation?
Yes No Do you use/have any volunteer, donated, or seasonal employees?
Yes No Do any employees travel and/or work out of state?
Yes No Do you require pre-employment testing for alcohol/drugs, flexibility/dexterity/strength, or for hearing?
Yes No Has your company ever had an EEOC suit or complaint?
Yes No Do you have formal, written safety programs in place?
Yes No Have any employees missed work for more than five (5) days during the last three (3) months due to injury or illness?

If you answered yes to any of these, please provide additional information for the specific question: (ALSO: Please provide any comments or special instructions)
Privacy Statement:
Thank you, the information which you give in completing this form will be forwarded directly to First Sun for its sole use and will only be shared with potential providers. The information will not be used for any other purpose or provided by us (or our providers) to any other parties. PLEASE PRINT A COPY FOR YOUR RECORDS BEFORE SUBMITTING.

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