Alrich & Associates

Independent PEO Brokers

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PEO - Employee
Leasing

PEO - Employee Leasing

Submit This Form to get Your Quote.

Date (mm/dd/yyyy)

Main Contact

Company Name
D/B/A

Main Address

State

ZIP

Phone

FAX

E-mail

In order to provide an accurate cost analysis, we need the following.

1. # of Full Time Employees
2. # of Part Time Employees
3. # Federal ID Number
4. Date Business Started	(mm/dd/yyyy)

5. Pay Cycle (Check all that apply)

Weekly

Bi-Weekly

Semi Monthly

Monthly

6. Approximate Annual Gross Wages

or Monthly

7.* Copy of Current Unemployment Tax Rate Notice (Ga DOL-626) or RATE

8.* Copy of Current Worker's Compensation Declaration Sheet (shows wages by category)

9. Workers Comp Deductible

Modifier

10. Current Payroll Plans: 401K

Sec 125 (cafeteria)

LT/ST Disability

11. Dental

Vision

Medical Savings

Life

Supp Health

12. Current Health Insurance Carrier

13. HMO

PPO

Standard Indemnity

Group (If applicable)

14.* Copy of Current Health Insurance premium billing statement

15.* Copy of Current Health Insurance premium billing statement

16. Number of Employees covered under current plan
17. Percentage of employee benefits funded by company	%

Health Plan Participants	Work Comp Codes	# of Employees	Gross Wages
Employee Only
Emp + Spouse
Emp + Child(s)
Emp + Family
Exempt

If unavailable separately, please include a copy of a recent invoice. After completion, please return with attachments to:*

Alrich & Associates
2030 Crossover Drive
Cumming GA 30040

Or by FAX
770-888-5358

Or by E-mail
Ted@alrich.com

If you have any questions, comments, or concerns, please contact your local representative or call Alrich & Associates directly at 770-844-6428. We thank you for your interest.

Contact Us sales07@alrich.com 770-844-6428

© copyright 2003 Alrich & Associates

PEO - Employee Leasing

Submit This Form to get Your Quote.

In order to provide an accurate cost analysis, we need the following.

If unavailable separately, please include a copy of a recent invoice. After completion, please return with attachments* to:

Alrich & Associates2030 Crossover DriveCumming GA 30040

Or by FAX 770-888-5358

Or by E-mailTed@alrich.com

If unavailable separately, please include a copy of a recent invoice. After completion, please return with attachments to:*

Alrich & Associates
2030 Crossover Drive
Cumming GA 30040

Or by FAX
770-888-5358

Or by E-mail
Ted@alrich.com