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RFP - Application
Step
1
of
5
20%
Company Information
Company
*
DBA
Website
*
Company Description
Owner Information
Owner Name
*
First
Last
Owner Job Title
Owner Phone
*
Owner Email
*
Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Contact
Owner is Primary Contact
Owner is Primary Contact
Name
First
Last
Title
Phone
Email
General Information Comments
Industry Information
Industry
SIC Code
SIC Description
NAICS Code
NAICS Description
Do you utilize subcontractors?
Yes
No
Current subcontractors COI on file?
*
Yes
No
Industry Comments
Payroll Information
Annual Payroll Data
State
Comp Code
Full-Time Employees
Part-Time Employees
Gross Annual Wages
Pay Frequency (Pay Cycle)
Current WC Rate
Current SUTA Rate
Actions
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State Codes.
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Most Recent Payroll Report
(Line Item Employee/Gross Pay/Tax Deductions/Deductions/Net)
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Accepted file types: pdf, xlsx, xls, doc, docx, txt, csv, Max. file size: 25 MB, Max. files: 5.
Hidden
Secretary of State Status Reports
(Please upload a valid report for each State.)
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Accepted file types: pdf, xlsx, xls, doc, docx, txt, csv, Max. file size: 25 MB.
State Unemployment Tax Reports
(Please upload valid reports for each State.)
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Accepted file types: pdf, xlsx, xls, doc, docx, txt, csv, Max. file size: 25 MB.
Requested 1st Pay Date
*
MM slash DD slash YYYY
Requested 1st Pay Period Start Date
MM slash DD slash YYYY
Interested in 1099 Services
Yes
No
Payroll Comments
Premium Options
SBA Application Assistance
Yes
No
Time & Attendance
Yes
No
Application Wrap-up
SBC (Strategy Business Consultant)
*
Already working with an eESI SBC? Please select from the list below.
No - Assign based on location.
Corey Hookstra
Steven Hookstra
Rick Laurel
Brian Rothermel
Debbie Carpe
Marlene Wanzong
Marcela DeBotte
Referral
Authorized Contract Signer
Primary Buying Motivation
Additional Employment Challenges
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Email
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