Employee Leasing Company Licensure And Registration Application Form Page 2
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2Certification and Requirements
u The company certifies that we do not conduct a temporary help business through the same entity as the
employee leasing business.
u The company agrees to maintain separate records for each client company and file reports as required by
law for each of our client companies as required under 1033(4)(B) of Title 21.
u The company agrees to pay unemployment contributions and workers' compensation premiums based on
the experience rating of each client company as required under 1033(4)(C) of Title 21.
u The company acknowledges our joint and several liability with each client company to protect the health,
safety or welfare of an individual leased to a client company.
u The company will attach an audited financial statement and evidence that it has deposited securities or
posted a bond in an amount not less than $100,000.00 or 5 percent of liabilities, whichever is greater as
required under 1033(7) of Title 21. The financial statement shall have been prepared within six months of
the date of application by an independent certified public accountant licensed in this state pursuant to 21
V.S.A 1035 (a).
u The company agrees that the commissioner may liquidate any securities or bond provided upon our
default in paying wages, benefits, workers' compensation premiums or awards of unemployment
compensation premiums.
u The company agrees to adhere to "Unemployment Insurance Requirements" as indicated on enclosed
form EL-5.
By signature below, I certify that the foregoing information is true and accurate.
________________________________
______________________________
Applicant or authorized agent
Date
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