Free Professional Employer Agreement Notice - Arizona

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 Emplo yer Agreement with (name of client employer) , referred to as "client employer" in this Notice. The following information is provided with respect to that Agreement and client employer: 1. Full legal name of client employer, including all other names ("aka's") under which the client employer operates. ___________________________________________________________________________ ___________________________________________________________________________ 2. FEIN # of client employer. _____________________________________________________ 3. Addresses of all locations of client employer (attach separate paper for additional locations). Location 1 _________________________________________________________________ Location 2 _________________________________________________________________ 4. For each location of client employer, are all employees covered (leased) under the PEO agreement? Answering "yes" means all employees at a particular location are covered (leased) employees under the PEO agreement. Answering "no" means some or all employees at a particular location are not covered (not leased) employees under the PEO agreement (attach separate paper for additional locations). Location 1 Yes:____ Location 2 Yes:____ No:____ No:____

5. If you answered "no" to Question no. 4 for any location listed, state the policy number and 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.

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Dated this __________ day of _______________________, 2____ _______________________________________ Printed Name of PEO _______________________________________ Authorized Signature _______________________________________ Printed Name and Title of Person Signing
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. § 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.