Type of Registration:

Organizational Structure:

Name of PEO:

Date of Organization:

Unemployment Compensation Account #

Federal ID #

Business Address:

City, State, Zip:

Telephone:

Fax:

Web site:

Name

Business Address:

City, State, Zip:

Telephone:

Fax:

E-Mail Address:

Name :

Business Address:

City, State, Zip:

Telephone:

Fax:

E-Mail Address:

Is the registrant domiciled outside the state of Alabama and registered or licensed as a PEO in another state with substantially the same or greater requirements of the Alabama Professional Employer Organization Registration Act?

If yes, specify the state(s):

Does the registrant maintain an office in this state or solicit clients located or domiciled within this state?

Please provide the number of covered employees employed or domiciled within the state on any given day.

Has the applicant commenced operations in Alabama prior to this registration?

If yes, on what date did the registrant commence operations?

If yes, what is the dollar amount of registrant's current gross Alabama payroll?

Please provide proof of Alabama worker' compensation insurance coverage with an ORIGINAL Certificate of Insurance from a carrier properly licensed by the Alabama Department of Insurance;

Are the premiums on the policy as of the date of this registration paid in full?

If the answer to the previous question is NO, are the unpaid amounts in dispute with your insurance carrier?

If any amounts are in dispute, please list the name of the carrier(s), the policy number(s), the period(s) covered, and the amount(s) in dispute.