Notice Of Professional Employer Agreement

A PEO is required to file this Notice with the PEO's Workers' Compensation Insurance Carrier and The Industrial Commission of Arizona when a PEO enters into a Professional Employer Agreement with a client in Arizona. When the Agreement is terminated, the PEO shall immediately notify its Workers' Compensation Insurance Carrier and The Industrial Commission of Arizona. A.R.S. 247 23-901.08. This Notice may be faxed to The Industrial Commission of Arizona c/o Insurance Supervisor at (602) 542-3373. The Industrial Commission of Arizona complies with the Americans with Disabilities Act of 1990. If you need this Notice in alternative format, contact Claims at (602) 542-4661. NOTICE OF PROFESSIONAL EMPLOYER AGREEMENT The undersigned Professional Employer Organization ("PEO") hereby serves notice to its Workers' Compensation Insurance Carrier and The Industrial Commission of Arizona that it has entered into a Professional Employer Agreement with , referred to as "client employer" in this Notice. The following information is provided with respect to that Agreement and client employer: Full legal name of client employer, including all other names ("aka's") under which the clientemployer operates.FEIN # of client employer. Addresses of all locations of client employer . For each location of client employer, are all employees covered (leased) under the PEOagreement? Answering "yes" means all employees at a particular location are covered(leased) employees under the PEO agreement. Answering "no" means some or all employeesat a particular location are not covered (not leased) employees under the PEO agreement(attach separate paper for additional locations). No: No: 5.If you answered "no" to Question no. 4 for any location listed, state the policy number andPrinted Name of PEO Authorized Signature Printed Name and Title of Person Signing name of the workers' compensation insurance carrier (not TPA or servicing agent of carrier)providing coverage to the non-leased employees of the client employer. Signing American LegalNet, Inc. www.FormsWorkFlow.com