Professional Employer Organization New Client Form Page 2
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1
2Professional Employer Organization (PEO)
New Client Form (Continued)
Are any executive employees, listed by name as covered employees, on the PEO services agreement?
Yes ___ No ___
If yes, provide information below on covered corporate officers, managing members of an LLC, sole
proprietors or partners:
Name
Title
Duties
Ownership %
Incl/Excl
_________________
____________
_________
_______
_________
_________________
____________
_________
_______
_________
_________________
____________
_________
_______
_________
_________________
____________
_________
_______
_________
Is client coming out of a contract with another PEO? Yes ___ No ___
If yes, provide names of all PEOs and exact contract dates:
Name
Exact contract dates (agreement date, termination date)
____________________
____________________________________________________
____________________
____________________________________________________
____________________
____________________________________________________
Completed by: _______________________________ Date: ______________
This form must be completed and provided to Texas Mutual Insurance Company no later than 10
days after agreement’s effective date. Please email to or fax to
“Attn: Underwriting“ at (800) 359-0650.
PEONEWCL
Page 2
Rev. 07/15
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