New Client Leasing Census Company Information Company Name Business Address Business Address Business Address Business Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Business Phone Business Fax NOTE: If you have more than one business location, please put additional locations in the "Other Information" field located at the bottom of the page. Company Status New Existing State of Incorporation Date of Incorporation Company Type Sole Proprietor LLC (Limited Liability Company) Corporation Partnership OtherOther Federal ID Number (EIN) Nature of Business/Trade Owner/Officer Information please list the main contact owner first. Name Title SSN Date of Birth Ownership% Annual Remuneration Estimated Email Phone Add Remove Other Authorized Contacts Name Title Email Phone Add Remove Payroll Data Leasing all Employees Yes No Number of Employees Payroll Frequency Weekly BiWeekly Monthly OtherOther Accrued Time Tracking None Sick Pay Vacation Personal OtherOther Accrual Policy Detail please indicate how you compute accrued time for each type checked off. Payment and Delivery Prepayment Requirement: We require all payroll exposure to be covered by guaranteed funds before we will release your payroll. If you plan to set up automatic drafts from your account to pay for invoices (this is the typical choice), then a prepayment is required to remain on hand with us. This can be paid up front with guaranteed funds, or we can bill this prepayment over 5 installments, but you will need to pay with guaranteed funds until the full amount is established. I have read and understand the Prepayment Requirement * Yes No Method of Payment Automatic Draft (prepayment required) Wire Transfer by Customer If you are paying by Wire Transfer we will only release payroll once the wire has been received. If you select Automatic Draft, please provide your bank name, the bank routing number, your account number and account type. Bank Name Bank Routing/ABA Number this will be 9 digits Account Number Account Type CheckingSavings Payroll Delivery Options Regular Mail Fedex (fee applies) Pick up at Rye office Workers Compensation Coverage Do you currently have a Workers Compensation policy? Yes No Workers Comp Carrier Name Workers Comp Classifications please list the codes on your policy, or attach a copy of the Workers Compensation Classification Page (upload button below). Codes appear formatted like: "8810" and will have estimated wages listed alongside. Other Information Please add any other pertinent information, requests or questions you may have. Employee Census Please complete this schedule for each employee or you may upload a payroll register using the upload feature (below) or in a separate email. Employee Name Initials can also be used. Rate of Pay Average Hours worked per week WComp Code per the classifcation schedule Job Description or title Add Remove File Upload Drop a file here or click to upload (jpg, jpeg, jpe, png, gif, pdf) Choose File Maximum file size: 268.44MB Authorization Submitted By: Full Name Title Date Signature Clear If you are human, leave this field blank. Submit