MED PEO | Request for Proposal(RFP)

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Request for Proposal

Request for Proposal (RFP)

Please complete this Request for Proposal (RFP) to receive rates from qualified PEO's who specialize in the healthcare industry in your state. Please indicate any special requirements or needs of your business.

To provide the most accurate proposal, we need the following information e-mailed or faxed to us in addition to the completed RFP form below:

Current declaration page from current Workers' Compensation policy
Last three years of Workers' Compensation "loss runs"
A SUTA (State Unemployment Tax Act) report or your annual rate notice indicating current rate

All fields marked with * are required.


Contact Name:*

Company Name:*

Tax I.D. or S.S.#:*

Business Entity:*	C-Corporation S-Corporation LLC Partnership Sole-Proprietor LLP Other

Company Address:*

City:*

State:*

Zip: *

Company Web Site URL:

Primary E-mail Address:*

Secondary E-mail Address:

Phone Number:*

Fax Number:*

Cell Phone Number:

When is the best time to contact you?

About Your Company

Describe Your Business:

Do You Currently Use a PEO?*	Yes No

If Yes, Name of PEO:

Do You Currently Use a Payroll Service?	Yes No

If Yes, Name of Payroll Company:

Do You Have Operations in Other States?	Yes No

If Yes, Name of States:

Have You Been Cited for Any OSHA Violations in the Last Three Years?	Yes No

Is Your Company Engaged in Work Not Described Above?	Yes No

Current Number of Full-Time Employees:*

Current Number of Part-Time Employees:*

Workers' Comp Modifier: (if known)

Gross Payroll:*
Per Pay Cycle*	Week Bi-Weekly Semi-Monthly Monthly Annually

Workers' Comp Code(s):*
	The 4 digit number(s) listed on your workers' compensation certificate, such as "8810 - clerical"

	Code 1:	Payroll/Code 1:
Payroll per Workers' Comp Codes:*	Code 2:	Payroll/Code 2:
	Code 3:	Payroll/Code 3:
	Code 4:	Payroll/Code 4:
	Code 5:	Payroll/Code 5:
	Code 6:	Payroll/Code 6:


Current Pay Cycle:*	Week Bi-Weekly Semi-Monthly Monthly Annually

Current SUTA Rate:*	State Unemployment Tax Rate (%)


Do You Currently Offer Medical Benefits for Your Employees?	Yes No

If Yes, When is Your Renewal Date?	(Format: mm/dd/yy)

What is Your Medical Deductible?


Benefits of Interest:	Medical Insurance
(check all that apply)	Life Insurance
	Dental Insurance
	Vision Insurance
	401(K) Retirement Plan
	Pre-Tax Cafeteria 125 Plan
	Prescription Drug Coverage
	Flexible Spending Account (FSA)
	Personal Accident Insurance
	Long-Term Disability Insurance
	Short-Term Disability Insurance
	Supplemental - Cancer, Accident, Hospital
	Credit Union Membership
	No Benefits

How Did You Hear about Us?

Additional Questions/Comments: