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

APPLICATION FOR CERTIFICATION AS AN EMPLOYEE-LEASING COMPANY

Unemployment Insurance Account Number

Federal Employer Identification Number

18. To obtain certification as an employee-leasing company conducting business in Colorado, you must provide evidence of

your ability to pay UI premiums for all work-site employees. You must select one of the following methods by which you will

provide this securitization to the UI Program:

Execute and file a surety bond, letter of credit, or cash escrow equal to 50 percent of the total UI premiums

assessed during the previous calendar year. The initial security amount for a new employee-leasing company is

equal to the standard UI rate (.0170) multiplied by 50 percent of its projected chargeable payroll for the current

calendar year as estimated by the employee-leasing company.

NOTE: Before the security amount can be determined, you must complete and return the enclosed Form UITL-39,

Coemployer Annual Report and Certification, and a list of work-site employers and work-site employees as

described on Form UITL-72, Report of Work-Site Employers and Employees. Upon review of these documents,

the UI Program will send you Form UITL-73, Employee Leasing Company’s Election to Submit Security, for your

completion and return with the required security.

Provide the most recent independently audited financial statement prepared by a certified public accountant using

generally accepted accounting principles, which demonstrates that you have an accounting working capital of not

less than $100,000. The financial statement must be no older than 13 months.

NOTE: If you select this option, you must include the required independently audited financial statement when

you return your completed application.

Receive and provide an annual accreditation by a qualified, bonded, and independent assurance organization as

approved by the Colorado Department of Labor and Employment.

NOTE: If you select this option, your accreditation as an employee-leasing company (signed by you and the

assurance organization) must be received along with your completed application. The accreditation must provide

certification of compliance with all applicable laws and regulations of the Colorado Employment Security Act

(CESA) and the Regulations Concerning Employment Security.

Payment of a nonrefundable fee of $500 must accompany this completed application. Make your check payable to the Colorado

State Treasurer, and, if applicable, include your employer account number on your check. Do not send cash.

I acknowledge that I have read and understood the rights, requirements, and responsibilities set forth for employee-leasing

companies and work-site employers under CESA 8-70-114 and 8-76-104 (8).

I certify that the information provided as part of this application is true, correct, and complete to the best of my knowledge.

Name of Owner, Partner, or Corporate Officer

Title

Signature

Date

UITL-71 Reverse (R 03/2010)

Form Uitl-71 - Application For Certification As An Employee-Leasing Company - 2010 Page 2