New Client Submission -- T&T Staff Management

Client Identity

Client Name

Client Entity Type

Client FEIN

Location Code

Client Physical Address

Client Email

Client Phone

Coverage Details

Agreement Date

Leave blank if not yet known -- this is finalized once Texas Mutual approves and T&T signs the client.

Number of Covered Employees

Client's Experience Modifier

NCCI ID#

Experience-Mod Worksheet

Attach a copy of the experience-mod worksheet if you have one -- if not, Mt. Franklin will follow up.

Classification Codes & Annual Payroll

One row per classification. Not sure which class code applies? Leave the code blank and describe the work -- Mt. Franklin will confirm it before anything is sent to Texas Mutual.

Class Code

Description of Operations

Annual Payroll

Covered Officers / Members / Partners

Duties: 1 = Clerical or Sales, 2 = Exec. Supervisor, 3 = Working Foreman.

Name

Title

Duties

Ownership %

Include/Exclude

Non-Covered Officers / Members / Partners

Excluded from the workers' comp policy.

Name

Title

Prior PEO History Is this client coming out of a contract with another PEO?

No Yes

Submission Completed By (your name)