Entity Name

DBA

Company Phone Number

Address 1

Address 2

City

State StateSelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington, DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisiannaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HamshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashintonWest VirginiaWisconsinWyoming

Zip Code

Contact First Name

Contact Last Name

Title

Email Address of Contact Person

Contact Phone Nuber

Other Entity Locations

Is the entity, directly or indirectly, controlled by any other corporation, or does it operate pursuant to a management or service agreement with any entity other than a customer/lessee? Is the entity, directly or indirectly, controlled by any other corporation, or does it operate pursuant to a management or service agreement with any entity other than a customer/lessee?Select oneYesNo

If yes, list names

Year Business Started

Number of Employees

Annual Revenue

State of Incorporation State of IncorporationSelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington, DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisiannaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HamshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashintonWest VirginiaWisconsinWyoming

Number of Clients

List Officers, managers, and affliates authorized to bind the Applicant

Every name the Organization has operated under and the correct mailing address of each of its offices for the past 5 years (including any alternative names and names of predesessor and successor entities and names of any affliates) along with the policy number and carrier for each workers' compensation policy issued to the Organization under each and every such name in the past five years.

New Field

Is the Organization of Professional Employer Organization (PEO) under its current name, or any name the firm may have at any time operate under? If yes, please list the name(s) of the company(s).