Professional Employer Organization New Client Form
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26210 East Highway 290
Austin, TX 78723-1098
(800) 859-5995
Fax (800) 359-0650
Professional Employer Organization (PEO)
New Client Form
Completion of this form does not guarantee coverage for this client. Underwriting must review and
specifically approve each client.
PEO name: ___________________________________________ Policy number: ______________
**PEO name on signed agreement must match the name on the license**
Client name: __________________________________________ Location code: ______________
Client entity type (corp., sole prop., etc.): ___________________ Client FEIN:
______________
Client physical address: _____________________________________________________________
Agreement date: ________________________ Number of covered employees: _______________
**Agreement date is the first day of the payroll period that the client above is a co-employer**
Client’s experience modifier: ________ NCCI ID number: __________ (attach a copy of worksheet)
Client classification codes and annual payrolls for covered employees:
Class code
Description of operations
Payroll
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PEONEWCL
Page 1
Rev. 07/15
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Parent category: Business