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HUMAN RESOURCES INC.

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Human Resources, Inc., & Subsidiaries

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Client Profile / RFP

Client Name:*

Address:

City:

State:

Zip:

Phone:

Fax:

Payroll Contact Person:

E-mail:*

Payroll Information

Payroll Cycle is:

Weekly

Biweekly (every other week)

Start Accruing Payroll
(1st day of Pay Period)

Pay Period Ending
(last day of Pay Period)

Payroll Called In to HRI by
(2 days before check date required)

Check Issue

Desired Delivery

Payroll Delivery

U.S. Mail invoice and checks to client (only if all on Direct Deposit)

No Charge

Yes

Federal Express, UPS Overnight

*Current Rate based on availabilty

Yes

Other (e-mail invoices, check stubs online)

Payment Method

ACH Debit

Yes

Company Check

Yes

Bank Wire

Yes

Certified Check/Money Order

Yes

Corporate Information

Entity Type

Sub S

C Corp

LLC

Other

Owner / Officer Information

Officer	*	Title
Officer	*	Title
Officer	*	Title
Officer	*	Title
Officer	*	Title

Human Resource Issues

Are there any EEOC / EE related issues/ litigation pending?

Yes

If Yes, please explain:

Have you ever been through a Department of Labor Audit?

Yes

If Yes, please explain:

Is there an employee Handbook? If Yes, Please provide copy.

Yes

Are pre- / post-employment background investigations performed on new hires?

Yes

Comments:

Is pre-employment drug testing done?

Yes

Is random drug testing done?

Yes

Comments:

Is there a current 401(k) plan in place?

Yes

If Yes, will the plan be rolled over to our plan?

Yes

If No, is there any interest in offering a 401(k) plan to the employees?

[29763 - If No, is there any interest in offering a 401(k)]

Is there a current Benefit plan in place?

Yes

If Yes, please describe:

Is there a Section 125 Plan in place? (enables employee to make pre-tax insurance deductions)

Yes

What benefits would interest your employees?

Dental

Vision

Major Medical

Supplemental

How many W2s did your company issue last year?

How many unemployment claims were filed in the past year?

Please attach copy of UCT-20 “Unemployment Tax Rate Notice” or last quarter’s UCT-6 “Employer’s Quarterly Report”

Workers’ Compensation

Description of Operations:

State of work	WC class code	Position / Job Description	# of Employees	$ Annual Wages
				*
				*
				*

Is there a safety manual or written safety policy? If yes, please attach.

Yes

Do you have any current safety needs? Please describe.

Attach copy of current Workers’ Compensation declarations page.

Attach 3 years of carrier generated loss runs. If cannot be provided, provide 3 years of OSHA logs or a “No Loss Letter” for time-in-business or past 3 years.

Provide details of all WC claims > $25,000.00

Describe any special service needs, i.e., Special Reports, Multiple Tax Jurisdictions, etc:

Do you use subcontractors?

Yes

Subcontractor Minimum Policy?

Yes

Signature

Signature:

Date: