Name:
Title:
Company:
Address:
City:
State:
Zip:
Phone number:
Fax number:
Email:
Would you like to receive our monthly newsletter? yes no
How did you hear about us?
Do you use an outside payroll service? yes no
Are you currently with a PEO? yes no
Number of employees:
Industry:
Number of years in business:
Do you work in multiple states? yes no
If so, which ones?
What service areas are you interested in?
	Employee Benefits/Admin
	Section 125 Flex Plan
	Payroll Processing
	Human Resource Consulting
	Risk Management Services
	Workers’ Compensation
Do you offer benefits to your employees? yes no
Benefits provided:
	Medical
	Dental
	Vision
	401(k)
	LTD
	STD
	Accidental Death/Dismemberment
	Other
Is there anything else you would like to tell us?