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Producer Number Producer Name
General Information ALL Titles in RED are Required
Company Name
Street Address
Suite City State Zip
Select One YES NO Contact Name Title Are You The Decision Maker
Contact Phone Contact Fax Ext.
Contact Email
Confirm Contact Email
Payroll Processing Information ALL Titles in RED are Required
Select One Weekly (52) Bi-Weekly (26) Semi-Monthly (24) Multiple Frequencies Processing Frequency
Estimated Number of "Live" Checks Each Pay Period
Estimated Number of Direct Deposits Each Pay Period
Select One 1 2 3 4 5 6+ Number of Federal E.I.N.'s to be Processed
Select One 1 2 3 4 5 6 7 8 9 10+ Number of States With Operating Locations or Employees
Select One YES NO Not Sure - Please Provide Additional Information Are You Interested in a Pay Card Solution
Select One Immediately Start of the Next Month Start of the Next Quarter Just Looking What is Your Implementation Time Frame
Select One YES - Full Tax Processing NO Select One Checks Drawn on My Bank Checks Drawn on Your Bank Not Sure Select One Yes - I Need a GL Export No - I Have No Need Not Sure Payroll Tax Processing Options Banking Options General Ledger Exports Options
Select One YES NO Not Sure Are Special Reports Required If "YES" Please Describe Your Needs Below in the Comments Section
Do You Currently Have in Place Any of the Following Section 125 FSA HRA HSA 401K Payroll Deducted Work Comp
Time & Attendance Information
Select One YES - Please Provide Additional Details Below NO - Not At This Time Are You Interested in a Time & Attendance Solution
Estimated Number of EE's on Time & Attendance Platform per Month:
Optional Products and Services Please Check the Boxes Next to Any Item That You Would Be Interested in Obtaining More Detailed Information
HR Knowledge Base COBRA Administration Dependent Eligibility Audits Unemployment Tax Assistance
Payroll Deducted Work Comp H. R. M. S. Voluntary Benefits Programs Risk Financing Solutions
125 - FSA - HRA - HSA Employee Benefits Enrollment 401K Services Merchant Services
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