COMPANY PROFILE

All information obtained is used to create a free, confidential, no obligation quote. The information you provide will be kept confidential. We will share it only with our PEO partners for the purpose of preparing price quotations. General Information Company Name   (show US company name if your company is the US subsidiary of a non-US corporation) Address    City   State   Zip Code   Phone Number  Fax Number  E-mail Address  Principal Contact Person   Title   Owner(s)/Principal(s) Nature of Business Federal Tax ID Number  Home State Unemployment Tax Number  Type of Corporation: C Corp S Corp Partnership PA LLC Other  Years in Business in the U.S. Parent Company (if applicable) Address

Additional Locations Number of Locations: Address            Address            Address

Workers' Compensation Information Current Carrier Broker  Experience Modifier  Effective W/C Discounted Factor   Renewal Date  Gross payroll per Workers’ Compensation Class Code per year: Job Class (e.g. sales, clerical) Class Code Annual Payroll For Code $ # of EEs per code   Do you currently have in place: Written Safety Program  Yes  No OSHA 300 Log  Yes  No Do you own, operate or lease aircraft, watercraft?  Yes  No Any exposure to flammable or hazardous materials?  Yes  No Any exposure to radioactive materials?  Yes  No Any work performed underground or above 13 feet?  Yes  No Any work performed on barges, vessels or docks?  Yes  No Are sub-contractors used?  Yes  No If sub-contractors are used, are current certificates obtained?  Yes  No Any group transportation used?  Yes  No Are athletic teams sponsored?  Yes  No Coverage been declined/canceled/non-renewed last 3 years?  Yes  No Does company use safety equipment?  Yes  No Does company use car/trucks for company business?  Yes  No If yes, are vehicles company owned?  Yes  No Is work performed under a wrap or Owner Controlled Insurance Program (OCIP)  Yes  No

Payroll Information Payroll Frequency  Weekly  Bi Weekly  Semi-monthly  Monthly Currently Outsourcing Payroll?  Yes  No If "Yes", cost of payroll processing $  If yes, name of company  # Of Full-time Ees  # Of Part-time Ees  Gross Annual Payroll $  State Unemployment Insurance Rate   ($0.00/$100) (If in multiple states provide a copy of the most recent State Quarterly Reports) Bonus, commission or incentive program?  Yes  No Tipped employees?  Yes  No Do you have a time and attendance system in place?  Yes  No If yes, which one?       Are you presently using a remote data entry product?  Yes  No If yes, which one?       Are any employees paid on piecework?  Yes  No Are any special payroll deductions required?  Yes  No Please provide details.

Human Resources Language(s) Spoken:  English  Spanish  Other If your business has experienced any investigations, lawsuits, or other proceedings in the last five years arising from violations, provide details: (i.e. state wage and hour regulations, EEOC, ADA) When screening or hiring new employees, do you:     Require a written application?  Yes  No Conduct background checks?  Yes  No Complete medical questionnaires?  Yes  No Require pre-placement physicals?  Yes  No Company policies     Are you regulated by any governmental agency for drug or alcohol testing? (i.e. FAA, DOT, etc.)  Yes  No Are you a Drug Free Workplace? If yes provide methods of testing      Second Chance    Auto-Termination      Yes  No Conduct performance evaluations?  Yes  No If yes, how often?      Have job descriptions in place?  Yes  No Do you use independent contractors?  Yes  No Is vacation/personal time off tracked?  Yes  No Employee handbook?  Yes  No

Benefits Information     Renewal Date (mm / dd / yyyy) Current Health Carrier Current Dental Carrier Current Life Carrier Current Short Term Disability Carrier Current Long Term Disability Carrier Other Benefit(s) Carrier(s) and renewal; dates – (please specify) Do you have a Section 125 Plan?   Yes       No Premium Only Flexible Spending Account-Dependent Care Medical Reimbursement Do you have a 401(k) Plan?   Yes       No Employer Match?  Yes       No If yes, specify contribution   Do you have Employment Practices Liability Coverage?  Yes      No Do you have an EAP (Employee Assistance Plan)?  Yes      No Employer’s Current Contribution Insurance Plan Single Ee Plus Child Ee Plus Spouse Family Health Dental Vision Life AD&D Long Term Disability XXXXX XXXXX XXXX Short Term Disability XXXXX XXXXX XXXX Other (Specify)  Other (Specify)  Other(Specify)   What is the eligibility period for benefits?  30 days  60 days  90 days    180 days  365 days If employer contributes different amounts ($ or %) by class of employee(s), please specify: Class    Amount   or %    Monthly Rates for Group Medical   Current Rates Renewal Rates Number of Emp. Eligible Number of Emp. Enrolled  Effective Date (mm/dd/yyyy)        XXXXXXXX XXXXXXXX  Single $  $   Employee & Spouse $  $   Employee & Child $  $   Family $  $

Health Plan Information 1) Total number of eligible full-time employees?   2) How many are enrolled in the current plan?   3) How many eligible employees are waiving coverage?   4) Current number of COBRA continuees?   5) What classes are eligible for coverage? full-time part-time retirees early retirees 6) Number of eligible part-time employees?   7) Has your group been declined for health coverage?   Yes     No 8) Are any employees or dependents pregnant?  Yes    No    If “Yes,” how many?   9) Have any employees missed 5 consecutive workdays or 10 or more days within a calendar year due to sickness or injury? Yes    No

The Following Documents Are Needed To Complete A Proposal Please send by Fax to (804) 273-9989 or Mail to: Affinity PEO 4510 Cox Road, Suite 111 Glen Allen, VA 23060 Workers’ Compensation Declaration Page Schedules or Descriptions – All Benefit Plans Workers’ Compensation Loss Runs (3 years) Employee Census (name, age/dob, sex, class, family status) Current Payroll Register Latest State Unemployment Report(s) If Unionized – Collective Bargaining Agreement Latest Invoice for each Benefit Plan Questions? Call 1-877-673-9797 (toll free)

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