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How Did You Hear About Us?*
Company Name*
Title
Main Physical Location*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Total Number of Employees*
How Many Part-time*
How Many Full-time*

Payroll Information
Payroll Frequency*
- Weekly
- Bi-Weekly
- Semi-Monthly
- Monthly
Does your company currently have a payroll service?*
- Yes
- No
General Business Information
Type of Business*

Year Founded*
Hour of Operation*
Short Description of Operations*
Do You Have Offices in Multiple States or Countries?*
- Yes
- No
Are You Engaged in any Other Type of Business?*
- Yes
- No
Do You Utilize Subcontractors?*
- Yes
- No

Benefit Information
Do You Have a Medical Plan?*
- Yes
- No
If Not, Do You Want One?
- Yes
- No
Do you have a dental, or vision plan?*
- Yes
- No
If Not, Do You Want a Dental, or Vision Plan?
- Yes
- No
Do You Have a Retirement Plan?*
- Yes
- No

Employee & Workers Compensation Information

Please Provide your work Comp Declaration page or complete the information below: (Below) Please list current combined annual payroll by WC Code with the # FT and PT Employees
Combined Annual Payroll
Please list code, Job Description, Number of FT Employees, Number of PT Employees, & Payroll (each on their own line). If you need to add more than one set, please fill out another field once it appears.
Combined Annual Payroll
Please list code, Job Description, Number of FT Employees, Number of PT Employees, & Payroll (each on their own line). If you need to add more than one set, please fill out another field once it appears.
Combined Annual Payroll
Please list code, Job Description, Number of FT Employees, Number of PT Employees, & Payroll (each on their own line). If you need to add more than one set, please fill out another field once it appears.
Combined Annual Payroll
Please list code, Job Description, Number of FT Employees, Number of PT Employees, & Payroll (each on their own line). If you need to add more than one set, please fill out another field once it appears.
Combined Annual Payroll
Please list code, Job Description, Number of FT Employees, Number of PT Employees, & Payroll (each on their own line). If you need to add more than one set, please fill out another field once it appears.
When is the Renewal Date for Workers Compensation?*
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?*
- Yes
- No
Privacy Statement: Thank you, the information which you give in completing this form will be forwarded directly to Complete Employee Services for its sole use. The information will not be used for any other purpose or provided by us (or our providers) to any other parties.
Name
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2700 Middleburg Drive, Suite 105
Columbia, SC 29204-2486
Phone: 803-255-8190

Toll Free: 1-833-CES-PEO1

Fax: 803-255-8194

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