Free lb0910R5.08NewAddress.pmd - Tennessee


File Size: 52.1 kB
Pages: 1
Date: April 29, 2008
File Format: PDF
State: Tennessee
Category: Workers Compensation
Author: CC30218
Word Count: 488 Words, 4,501 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.tn.us/labor-wfd/Employers/forms/LB-0910.pdf

Download lb0910R5.08NewAddress.pmd ( 52.1 kB)


Preview lb0910R5.08NewAddress.pmd
RETURN TO:

TN DEPT OF LABOR AND WORKFORCE DEVELOPMENT EMPLOYER SERVICES (STATUS/RATES) 220 FRENCH LANDING DRIVE NASHVILLE, TN 37243 (615) 741-2486 FAX (615) 741-7214

TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF EMPLOYMENT SECURITY

APPLICATION FOR CLIENT NUMBER
___
Tennessee ID# OFFICIAL USE ONLY M. No. SIC County Area

1A. Enter Staff Leasing Company Information Staff Leasing Co. State No. ___ ___ ___ ___ - ___ ___ ___

Staff Leasing Co. Name _________________________________ 1B. Enter Client Company Information Client's Federal Number ___ ___ - ___ ___ ___ ___ ___ ___ ___ Client's Employer Name _________________________________ Client's Trade Name _________________________________ Client's Mailing Address ________________________________ ___________________________________________________

Liab. Org.

First Employment

Date Liable

Rate

Comp Year

NAICS

M-NAICS

M-SIC

Previous No.

ROC

AUX-SIC

VERIFIED

2. Client's PHYSICAL BUSINESS ADDRESS in Tennessee if different from above: CLIENT'S COMPANY PHONE: ( _____ ) _____________ ________________________________________________________________ ________________________________________________________________ CLIENT'S FAX NUMBER: ( ______ ) ________________ ________________________________________________________________ CLIENT'S E-MAIL ADDRESS: __________________________________ NOTE: If client organization is exempt from Federal Income Taxes under Section 501(c)(3) of the IRS Code, attach a copy of letter of exemption.

3. CHECK (X) FORM OF ORGANIZATION
OF CLIENT COMPANY INDIVIDUAL PARTNERSHIP CORPORATION LIMITED LIABILITY COMPANY LIMITED PARTNERSHIP OTHER

4. Name of Client Company's Partners, Corporate
Officers, Limited Liability Company Members, and Managers (if Board Managed), General Partners (Attach separate sheet if necessary)

Social Security Number

Residential Address and Phone

NOTE: If client is a Limited Liabilty Company, are you treated by IRS as a(n)

Individual Proprietorship

Partnership or as a

Corporation

5. Name of person responsible for payroll records _____________________________________ 6. A. Number of client's workers in Tennessee __________

Phone Number _______________________

B. Date client's workers first employed by staff leasing company in Tennessee ____/____/____

C. Date client's workers first paid by staff leasing company in Tennessee ____/____/____ 7. Briefly describe the major business activity of the client company's account to be covered, listing any products produced or sold, or service provided. Be as descriptive as possible. ___________________________________________________________________________________

__________________________________________________________________________________________________________
In what Tennessee County is the client company located? __________________________________________________________________________ (If account covers sales reps or other personnel working from home, list county of residence. If county is unknown, list city of residence.)

For the work location covered by this application, is the main activity to: (Check one)
Supply products and services to the general public or other companies Support other locations of the client company (if you check this, please specify below) HEADQUARTERS (e.g. : Corporate or regional management offices) ADMINISTRATIVE, OTHER THAN HEADQUARTERS (e.g.: data processing, public relations) RESEARCH (e.g.: R & D, product testing, laboratory) STORAGE (e.g.: warehouse, distribution center, equipment yard) OTHER (please describe) (e.g.: Repair shop, security office, maintenance, employee recreation facility) _______________________________ Please check the box describing client company's major business activity:
Agriculture, Forestry, Fishing, Hunting Mining Utilities Construction Manufacturing Wholesale Trade Retail Trade Transportation and Warehousing Information Finance and Insurance Real Estate and Rental and Leasing Professional, Scientific, Technical Services Management of Companies and Enterprises Administrative and Support Services Waste Mgt. and Remediation Services Educational Services Health Care and Social Assistance Arts, Entertainment and Recreation Accommodation and Food Services Other Services __________________ _______________________________ Public Administration

Client Company Signature _________________________________________
LB-0910 (Rev. 05-08)

Title ___________________________

Date _____/_____/_____