Staff Wise

Client Application
Company       Dat      
Name: e:
Trade Name(if      
any):
Address:     
City:       State:   
Zip      
Code:
FEIN:          TWC Acct      Rate      
#: %:
What year established?      How many employees:    
Contact       Contact             
Person: Phone:
OWNERSHIP INFORMATION
Full Name:       Title      
:
Physical      % of    
Address: Ownership:
City:       State    Zip      
: code:
Home Phone:              Work             
Phone:

Full Name:       Title      

:
Physical       % of    
Address: Ownership:
City:       Stat    Zip      
e: code:
Home Phone:              Work             
Phone:

Full Name:       Title      

:
Physical       % of    
Address: Ownership:
City:       Stat    Zip      
e: code:
Home Phone:             Work             
Phone:
GENERAL QUESTIONS
In the past five years, has owner(s), member(s), stockholder(s) or active employee(s) been a defendant in any
criminal or civil legal proceeding regarding any employee abuse issues, including, but not limited to, assault,
battery, sexual harassment, race discrimination, age discrimination, wrongful termination, et cetera? YES
NO
Question above: If YES,      
Explain:
Do you currently have any Workers YES NO
Compensation Insurance?
If yes, do you have any past and/or YES NO
present claims?
PAYROLL
Estimated Yearly Gross       Workers Comp.      
Wages/Workers Comp. Code: Code or job
description:
Email: gdunavant@staffwiseusa.com or Fax: 972-987-4060
Page 1
Estimated Yearly Gross       Workers Comp.      
Wages/Workers Comp. Code: Code or job
description:
Estimated Yearly Gross       Workers Comp.      
Wages/Workers Comp. Code: Code or job
description:
Estimated Yearly Gross       Workers Comp.      
Wages/Workers Comp. Code: Code or job
description:
Estimated Yearly Gross       Workers Comp.      
Wages/Workers Comp. Code: Code or job
description:
Pay period: Weekly Bi-Weekly Semi-Monthly Monthly
If, more than one pay Weekly Bi-Weekly Semi-Monthly Monthly
period:
Desired payroll delivery: Paper Check Direct Deposit Debit Card
Pretax Benefits (Client Medical Dental HSA Other Insurance
Contribution 50%):
401-K
Comment      
s:
Signature
I, authorized personnel have completed Client Application. Under penalties of perjury, I declare that to the
best of my knowledge and belief, the Client Application is true, correct, and accurately lists all requested
information.

Authorized Personnel
Signature:

Email: gdunavant@staffwiseusa.com or Fax: 972-987-4060

Page 1