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Thank you for your interest in HRI, Inc., one of the top HR companies in the country, offering a top-notch team of HR consultants to serve clients across the United States. Please submit the information below and someone will follow up with you promptly.

Personal Information

Name

Address

City

State

Zip Code

Tel

Fax

Email

Cell Phone

Company Information

Company Name

FEIN #

DBA

Address

City

State

Zip Code

Tel

Fax

Web Address

Email

Whom is this application for

Individual

Agency

Do you have other brokers working for you?

Yes

Will you be providing quotes to other brokers?

Yes

Experience Level

(Attach Resume, or explain below, include number of years in each)

Current Licenses held

Insurance

Safety and Risk Management

PEO Sales

Payroll and Human Resources

Current Employer

Are there any Non-Compete or Non-Solicit Agreements with above employer?

Yes

List existing PEO relationships (if any)	Amount of Payroll with PEO
	*
	*
	*
	*

Give a brief description of your target clients (Blue, Grey, White collar)

Marketing Plans – How are submissions generated?

Projected Annual Volume

Number of employees	Amount of Payroll	Number of submissions
*	*	*

Involvement with Sales Process

Will you be the main point of contact during the proposal process?

Yes

Will you do client enrollments?

Yes

Background Information

Have you ever had a professional license revoked or suspended?

Yes

Have you ever had a felony conviction or fine by any state?

Yes

Have you filed for bankruptcy in the last 5 years?

Yes

Applicant Signature

Applicant Name

Date