Form Uitl-71 - Application For Certification As An Employee-Leasing Company

Colorado Department of Labor and Employment, Unemployment Insurance Employer Services, Premiums

P.O. Box 8789, Denver, CO 80201-8789

303-318-9100 (Denver-metro area) or 1-800-480-8299 (outside Denver-metro area)

APPLICATION FOR CERTIFICATION AS AN EMPLOYEE-LEASING COMPANY

1. Unemployment Insurance Account Number

2. Federal Employer Identification Number

If you do not have an unemployment insurance (UI) account number, you must attach a completed Form UITL-100, Application for

Unemployment Insurance Account and Determination of Employer Liability when you return this application. To download the form

go to and click on Forms & Publications.

3. Employer Name (Legal Business Name)

4. Trade Name (Doing Business As)

5. Business Address (include city, state, and ZIP code)

6. Colorado Business Address (if different from above)

If you have more than one Colorado business address, provide any additional addresses on another sheet of paper and attach.

7a. Contact Name

7b. Title

7c. Contact Telephone Number

7d. Contact E-mail Address

8. Provide the requested information for all owners and/or officers of a corporation. (Attach additional sheets of paper as necessary.)

Name

Title

Percent of Ownership or Interest

9. What percentage of your business is devoted to employee leasing?

10. How many work-site employers are contracted with your employee-leasing company in Colorado?

11. Do you specialize in providing employee-leasing services for any specific business or industry?

Yes

If Yes, specify the types of business or industry

12. Are you currently using any work-site employer’s UI account number for premium and wage reporting purposes?

Yes

13. You have two options for reporting for UI purposes and paying UI premiums. Indicate below which option you prefer (check

only one box).

Report and pay UI premiums as the employing unit under the employee-leasing company’s own UI account and rate.

Report UI premiums for covered employees under the respective UI accounts and rates for each work-site employer.

NOTE: If the employee-leasing company fails to make an election, the employee-leasing company shall report UI premiums for

covered employees under the respective UI accounts and rates for each work-site employer. In the future if your company is

already electing to report and pay UI premiums as the employing unit under your own UI account and rate, you will be permitted

to change the election one time after the initial election to report UI premiums under each work-site employer. Your election to

report UI premiums under the UI accounts and rates for each work-site employer is final and may not be reversed.

14. Are the owners or officers of any work-site employer also employees of your employee-leasing company?

Yes

15. Do you share ownership or interest with any work-site employers?

Yes

If Yes, provide the work-site employer names and your percentage of ownership or interest. (Attach additional sheets of

paper as necessary.)

16. Do your employee-leasing company and any work-site employer have common officers of a corporation?

Yes

If Yes, provide the work-site employer names and officer names and titles. (Attach additional sheets of paper as necessary.)

17. Are your employee-leasing company and any of the work-site employers operated in whole or in part by related family members

of either the employee-leasing company or work-site employers?

Yes

If Yes, provide the names and job titles of the family members and the name of the business the family member operates.

UITL-71 (R 03/2010)

Form Uitl-71 - Application For Certification As An Employee-Leasing Company - 2010

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