NEW CLIENT INFORMATION FORM - Outstaffing, Inc.

Date*

Legal Business Name*

Federal Tax ID *

SS# or Corporate EIN

Client First Name*

Client Last Name*

Business Address*

City*

State

Zip Code*

Client Email Address*

Client Cell Phone*

Office Phone*

Office Fax

Business Type*

If Other, specify

If complicated, please attach information

Ownership by Name and Percentage*

One owner/percentage per line

Briefly list main function(s) of Business*

Describe in Detail what your business does.*

Number of Hours in Standard Work Week*

State of Incorporation/Registration

Number of Full Time (W2s) Employees*

If none, "0"

Number of Part Time (W2s) Employees*

If none, "0"

Number of Independent (1099) Contractors*

If none, "0"

Active Workers' Comp Coverage?YesNo

If yes, Carrier

Policy Number

(Please Attach Workers' Comp Binder in the upload area below)

Any recent Unemployment/Workers' Comp Claims?YesNo

Upload Attachments

I certify that the information I have provided is accurate and will only be used to set up my business account with Outstaffing.com