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For
a free proposal from FirstSun, please complete the following
form and submit it to us, and fax/mail the requested support
documents. If you have questions, please call (803) 799-5020
or e-mail.
First Sun will ensure that information submitted will remain
private and confidential. Read the BellSouth
Privacy Statement.
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| How
did you find out about FirstSun? |
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other, please list |
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| Company
Name |
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| Main
Physical Address |
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| City
State
Zip
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| Contact
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| Title
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| Phone
# |
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| Fax
# |
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| E-Mail
Address |
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| Federal
ID # |
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| SIC
Code: |
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| Payroll
Frequency |
Weekly
Bi-Weekly
Semi-Monthly
Monthly
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Workers
Compensation Data
Include Owner(s) / Partner(s)
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Comments
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Renewal
Date |
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| General
Business Information |
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Type of
Organization |
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| Short
Description of Operations: |
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Year Founded |
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Hours of
operation: |
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| List
any other location including any outside the U.S. |
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| General
Information - Please explain Yes answers here |
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| A)
Are you engaged in any other type of business? |
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| B)
Are you a subsidiary of any other business? |
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| C)
Do you have any subsidiaries? |
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| D)
Do you use and/or have any volunteer, donated, part time or
seasonal labor? |
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| E)
Do any employees travel and/or work out of state? |
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| F)
Is pre-employment testing required for alcohol/drugs, flexibility/dexterity/strength
or hearing? |
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| G)
Do you have a formal written safety program in place? |
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| H)
Do you have a driver qualification program including MVR checks? |
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| I)
Do you use any sub-contractors? |
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| J)
Do you require certificates of insurance on all work you sublet? |
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| K)
Has your company ever had a EEOC suit lodged against it? |
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| L)
Do you own, operate or lease aircraft or watercraft? |
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| M)
Do you use any flammables, explosives, caustics or radioactive
materials? |
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| N)
Do operations involve the storage, treatment, discharge, application,
disposal or transport of hazardous materials? |
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| O)
Do you perform any work underground or above 15 feet? |
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| P)
Do you do any work on barges, vessels, docks, bridges or over
water? |
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| Q)
Has your company ever been cited by OSHA, EPA or the State for
violation of a law, regulation, or ordinance? |
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| R)
Has any employee missed work for more than five (5) during the
last month due to injury or illness? |
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| S)
Do you have a medical benefit program for employees? |
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| If
you answered yes to any of the above, please give additional
information as to why you answered yes. Identify explanation
by letter of question above. |
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Please
provide the following information for risk assessment purposes
(via Fax or Mail):
- Copy
of current information page and any extension pages (also
called Declaration Page)
- Copy
of latest two 941 Quarterly Federal Tax Forms (must be provided
prior to client coming on board)
- Copy
of last two (2) years loss runs (if loss runs are not available,
provide OSHA 200 logs)
- Copy
of latest SUTA return
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| Miscellaneous |
Does
your company have a payroll service?
Yes
No
What is the annual cost?
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Does
the company have a retirement program?
Yes
No
Annual cost to administer program:
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Does
the company have section 125?
Yes
No
Cost to administer plan:
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Do you
have a permanent office(s) in multiple states?
Yes
No
List states:
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