New Customer Summary

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General Details

Prospective Client Legal Entity Name*

Prospective Client Website*

Is this client associated with a VMS or MSP?*

Prospective Client Billing Address*

Street Address Address Line 2 City State ZIP Code

Worksite Address*

Street Address Address Line 2 City State ZIP Code

Is this role a remote position?*

Is there another worksite to add?*

Worksite Address (additional)*

Street Address Address Line 2 City State ZIP Code

Nature of work (Be descriptive- i.e., manufacturing: build & repair small boats, no work done on water or in shipyard)*

Job Specifics

How Many Jobs Do You Have?*

Job 1 Details

Job Title - Job 1*

# of Temporary Workers Requested - Job 1*

Estimated Payrate - Job 1*

Estimated Bill Rate - Job 1*

Contract Duration (Hours) - Job 1*

Estimated Annual payroll (payrate x # hours x # weeks) - Job 1*

Estimated Start Date - Job 1*

Do you have a file for your Job Description? - Job 1*

Upload Job Description - Job 1*

Accepted file types: doc, pdf, docx, docs, Max. file size: 128 MB.

If you don't have file to upload, write out Job Description using this field. The job description should be descriptive or it can not be processed by underwriting. - Job 1*

Has a job safety assessment been completed? - Job 1*

Job Site Risks, Hazards & Exposures - Job 1*

Is Personal Protective Equipment Required? (i.e PPE) - Job 1*

Does this client require a Certificate of Insurance? (COI) - Job 1*

Which screenings are requested by this client? - Job 1*

Have you discussed passing on costs of pre-employment screening to your client? - Job 1*

Which pre-employment drug screen or OHS screenings are requested? - Job 1*

Job 2 Details

Job Title - Job 2*

# of Temporary Workers Requested - Job 2*

Estimated Payrate - Job 2*

Estimated Bill Rate - Job 2*

Contract Duration (Hours) - Job 2*

Estimated Annual payroll (payrate x # hours x # weeks) - Job 2*

Estimated Start Date - Job 2*

Do you have a file for your Job Description? - Job 2*

Upload Job Description - Job 2*

Accepted file types: doc, pdf, docx, docs, Max. file size: 128 MB.

If you don't have file to upload, write out Job Description using this field. The job description should be descriptive or it can not be processed by underwriting. - Job 2*

Has a job safety assessment been completed? - Job 2*

Job Site Risks, Hazards & Exposures - Job 2*

Is Personal Protective Equipment Required? (i.e PPE) - Job 2*

Does this client require a Certificate of Insurance? (COI) - Job 2*

Which screenings are requested by this client? - Job 2*

Have you discussed passing on costs of pre-employment screening to your client? - Job 2*

Which pre-employment drug screen or OHS screenings are requested? - Job 2*

Client Contract Details

Name*

Job Title*

Email*

Phone*

Net Payment Terms*

Do you know the Accounts Payable/Accounting Department contacts yet?*

Conversion/Buyout Schedule (ex. 1040 hour prorated buyout)*

Conversion Placement Fee (ex. 25% of first year's annual salary)*

Would you like to provide any additional notes about this client?*

Additional notes about Client*

Important notes/details about client (i.e., requires vendor setup paperwork, PO#, etc.)*

Form Completed By*

Authorized Partner Name*

For an automated copy, please enter Email below (separate by semicolon if multiple emails)*

Name

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Job 1 Details

Job 2 Details

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