ࡱ>  @ bjbj)) KzKzjht....> }}}8}> rƒD (...@ ,@FHHHHHH$R Xle0^@00l....0...F0Fnj6. 0W}θr 4 03 l3 @|....3 ̣6$Ẓ̣̣ll> > DPY$$@> > Y STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS PROFESSIONAL EMPLOYER ORGANIZATIONS S.C. Code Ann. 40-68-10 et seq.  HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov (803) 734-4200 APPLICATION FOR PROFESSIONAL EMPLOYER ORGANIZATION RESTRICTED LICENSE (New or Renewal) (Complete all parts of this Application) Please submit an original and one (1) copy of the Application in ring binders. All information should be reduced to 8 x 11 size and arranged in the order set forth in the Application form. Please carefully review the instructions listed below for eligibility requirements. The application fee must be enclosed and is NOT refundable. Applications cannot be processed without the required application fee. The screening process may take as much as 90 days from the time this office receives the completed application, all required documentation, and appropriate fees. The Restricted License fee for Professional Employer Organizations (PEO) is: Five Hundred Dollars ($500.00) for each PEO and One Thousand Dollars ($1,000.00) for each PEO Group. All restricted licenses are valid for a period of two (2) years from the date of issuance. Please make all checks payable to the South Carolina Department of Consumer Affairs. South Carolina law permits the Department to issue a restricted license to a nonresident PEO or PEO Group for limited operation in this State if: (1) the applicants state of residence provides for licensing of PEOs, the applicant is licensed and in good standing in its state of residence, and the applicants state of residence grants a similar privilege for restricted licensing to PEOs or PEO Groups that are residents in South Carolina; (2) the applicant does not maintain an office, sales force, or representatives in this State, and it does not solicit clients that are residents in this State; and (3) the applicant does not have more than forty (40) leased employees working in this State. An applicant for a restricted license is exempt from the requirements of South Carolina Code 40-68-40(F). An applicant for a restricted license is required to retain and appoint a recognized and approved entity as its attorney to receive service of legal process issued against it in this State. Pursuant to the provisions of South Carolina Code 40-68-10 et. seq. (2001) as amended, the undersigned hereby makes the following statements for the purpose of obtaining a Restricted License to conduct business as a Professional Employer Organization (PEO) in the State of South Carolina. Name of PEO or PEO Group: FORMTEXT      Date of Organization: FORMTEXT      SC License #: (renewal) FORMTEXT      Unemployment Compensation Account#: FORMTEXT      Federal ID #: FORMTEXT      State ID #(withholding): FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone: FORMTEXT      Fax: FORMTEXT      Web site: FORMTEXT      Please indicate the type of license requested:  FORMCHECKBOX  New Restricted PEO License  FORMCHECKBOX  New Restricted PEO Group License  FORMCHECKBOX  Restricted PEO License Renewal  FORMCHECKBOX  Restricted PEO Group License Renewal Name of Primary Contact Person: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT       Name of Secondary Contact Person: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT       * Please provide the contact information requested below for the applicants current agent for service of process as registered with the South Carolina Secretary of States office. If you are not already registered, an Application for a Foreign Corporation for a Certificate of Authority to Transact Business in the State of South Carolina can be found on the South Carolina Secretary of States web site at  HYPERLINK "http://www.scsos.com" www.scsos.com. Name of Current South Carolina Agent for Service of Process: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No.: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT       Organizational Structure  FORMCHECKBOX  Corporation FORMCHECKBOX  Limited Liability Company FORMCHECKBOX  General Partnership FORMCHECKBOX  Limited Partnership FORMCHECKBOX  Sole Proprietorship FORMCHECKBOX  Other (specify) FORMTEXT       *Does the applicant maintain an office, sales force, or representatives in South Carolina? FORMCHECKBOX  Yes  FORMCHECKBOX  No *Does the applicant solicit clients that are residents of South Carolina? FORMCHECKBOX  Yes  FORMCHECKBOX  No *How many leased employees does applicant have working in South Carolina? Please provide a list of all leased employees using the Restricted License List of Leased Employees (Form PEO-16). FORMTEXT       State of Residency *What is your company s state of residence and/or incorporation? FORMTEXT       *Attach a copy of your company s PEO license or certificate from your state of residency. *Is your company in good standing in its state of residency? If yes, attach a copy of a letter of good standing from the licensing authority. If no, please explain.  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       *Does your state of residency provide for a restricted PEO license for out of state companies similar to the one granted in South Carolina? If yes, attach a copy of your state statute or regulation that grants this privilege to your application.  FORMCHECKBOX  Yes  FORMCHECKBOX  No South Carolina Client Companies Provide a list of all client companies in South Carolina. This information should be provided using either the Client Company List (Form PEO-07) or in a report that you generate provided, however, that all of the information requested in the table below is included in the separate report. Additions or deletions of clients should be reported to the Department within 30 days. Client CompanyFEINContact PersonMailing AddressCityStateZip:Telephone NumberFax NumberNumber of Assigned EmployeesDate Relationship InitiatedWorkers Compensation Business Classification CodeWorkers Compensation Carrier/Policy #Health Insurance Carrier/Policy # Other Information 1. Employment Tax Compliance Verification This information is required for all restricted license renewals and for applicants for a new restricted license that have commenced operations prior to obtaining a license. South Carolina law requires PEO licensees to assume responsibility for the payment of payroll taxes and for collection of taxes from payroll on assigned employees. Compliance with this obligation must be shown prior to the issuance of a license to provide PEO services in the State of South Carolina. In order to confirm that this obligation has been satisfied, the Department requires one procedure for federal taxes, and another for South Carolina state taxes. As of this year, the Internal Revenue Service has informed the Department that it will no longer issue the letter of good standing that the Department has accepted in the past. Therefore, for federal taxes, the Department now requires applicants for PEO licenses to execute copies of IRS Form 4506-T, which allows the IRS to provide a transcript of your tax returns to the Department. Applicants should use the edited and partially completed version of this form available on our website. For renewal licenses, the form is Federal Employment Tax Compliance Verification for 2007-2009 Renewal Application Form PEO-17. For new applications, the form is Federal Employment Tax Compliance Verification Form PEO-18. A copy of the appropriate form must be provided concurrently with, and dated the same as your Renewal Application. Forms PEO-17 and PEO-18 each contain two copies of Form 4506-T, because a separate signed form is necessary for your Employers Annual Federal Unemployment Tax Return (IRS Form 940), and for your Employers Quarterly Tax Return (IRS Form 941). Applicants must also request a letter of good standing from the South Carolina Department of Revenue. This letter should be requested from the following address for payroll periods ending no earlier than June 30, 2007: S.C. Department of Revenue Tax Compliance Officer Columbia, SC 29214-0027 Your letter of request to the SCDOR must indicate the PEOs South Carolina withholding account number. SCDOR will mail the compliance letter back to you. Applicants should forward the original letter from that agency to the Department for inclusion with their application for licensure. RELEASE: By the filing of this application with the S.C. Department of Consumer Affairs, the applicant specifically authorizes the release of any information by the South Carolina Employment Security Commission, the South Carolina Department of Revenue, and the Internal Revenue Service to the S.C. Department of Consumer Affairs regarding any payroll tax matters referenced herein, and holds those entities harmless from any consequences of such release. A photocopy of this authorization shall be as valid as the original. 2. Insurance Benefits Are the following insurance benefits provided to any leased employees in the State of South Carolina? Workers Compensation  FORMCHECKBOX  Yes  FORMCHECKBOX  No Health/Medical/Dental  FORMCHECKBOX  Yes  FORMCHECKBOX  No Life  FORMCHECKBOX  Yes  FORMCHECKBOX  No Disability  FORMCHECKBOX  Yes  FORMCHECKBOX  No If the answer to any of the above is yes, Applicant must provide: (a) a new Health Insurance Affidavit of Insurance (Form PEO-08) completed by each of the Applicants current Insurance Carrier(s); (b) a new Workers Compensation Affidavit of Insurance (Form PEO-09) completed by each of the Applicants current Insurance Carrier(s); (c) proof of workers compensation insurance with an ORIGINAL Certificate of Insurance from a carrier properly licensed by the South Carolina Department of Insurance; (d) a new Insurance Certification (Form PEO-10), which must be signed by a controlling person. (e) a completed Insurance Schedule (Form PEO-11) showing all current policy information; (f) a copy of each benefit plan or policy, including the declaration page; (g) a copy of all insurance benefits information that is provided to leased employees for all benefit plans; NOTICE Multiple Coordinated Policies. The South Carolina Department of Insurance has adopted a ruling by the NCCI that requires Professional Employer Organizations (PEOs) in the assigned risk market in South Carolina to operate under Multiple Coordinated Policies (MCP) for workers compensation insurance coverage. These policies require a PEO to apply for a policy in its own name for direct employees. The rule then requires the PEO to apply for coverage for each of its clients to cover employees leased to those clients. Policies are applied for in the client company name as the insured. The policies are then coordinated and the leasing company is billed for premiums with copies sent to client companies. If you are currently operating under a non-multiple coordinated policy, please contact your insurance carrier regarding this ruling. A copy of this ruling is available on our web site at  HYPERLINK "http://www.scconsumer.gov" www.scconsumer.gov. Are the premiums on all policies you listed on the Insurance Schedule (Form PEO-11) due as of the date of this Application paid in full?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If the answer to the previous question is NO, are the unpaid amounts in dispute with your insurance carrier?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If any amounts are in dispute, please list the name of the carrier(s), the policy number(s), the period(s) covered, and the amount(s) in dispute.  FORMTEXT       South Carolina Code 40-68-70 (B) requires PEOs that provide workers compensation insurance to client companies, before executing a service contract and on an annual basis, to conduct a good faith investigation to determine if the client company engages any nonassigned employees, including those considered employees under Title 42, in any part of the client companys trade, business, or occupation. The law also requires that upon a determination that a client company does include nonassigned employees, the service contract must require the client company to secure and maintain workers compensation insurance. Have you conducted such an investigation with regard to each of your client companies within the past year?  FORMCHECKBOX  Yes  FORMCHECKBOX  No South Carolina Code 40-68-70 (D) requires a PEO to report the information derived from these investigations to its workers compensation carrier. Have you made such reports in the past year?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. Audited Financial Statements Applicants must attach copies of the companys most recent Audited Financial Statement. Only audited financial statements will be accepted. The statement must be for annual periods ending no earlier than December 31, 2006, and shall be attested to by an independent Certified Public Accountant. If the most recent audited financial statement currently available is dated more than 180 days before the date of this application, the applicant must certify to the Department that there have been no material adverse changes in the financial position of the company since the date of the last financial statements, and shall provide a copy of the next financial statement as soon as it becomes available. The financial statements must include a statement of income and retained earnings, balance sheet, statement of changes in financial position (cash flow), and applicable footnotes. The financial statements also must reflect positive working capital and positive tangible net worth. The following items may be used to cover any deficit in net worth revealed by the most current financial statements in an amount sufficient to cover the deficiency: infusion of capital, an acceptable bank letter of credit, mortgages, a promissory note supported by collateral, or a guarantee where the guarantor can satisfy the S.C. Department of Consumer Affairs that the guarantor has sufficient assets to satisfy the obligation of the guarantee. Information supplied regarding net worth is proprietary and confidential and is exempt from disclosure to third parties. Note: All applicants must demonstrate a net worth of at least $50,000.00. Pursuant to South Carolina Code 40-68-40 (E), deficiencies in the net worth requirement as demonstrated by the Audited Financial Statements may be satisfied through guarantees, letters of credit, or other security acceptable to the Department in a combined total amount of at least $50,000.00. A guaranty is not acceptable unless the Applicant submits sufficient evidence to satisfy the Department that the guarantor has adequate resources to satisfy the obligations of the guaranty. Date of Financial Statement: FORMTEXT       Pursuant to Regulation 28-940, quarterly reports for financial income statements and balance sheets will be due for each quarter (3/31, 6/30/, 9/30 and 12/31) within 75 days after the end of each quarter on a going forward basis after issuance of a license. In these reports, licensees must demonstrate that premiums for health insurance, life insurance, workers compensation and other employee benefits have been paid to the proper payee; that working capital is in a positive position, and; that federal, state, and local payroll taxes have been paid as required by the regulations of each taxing authority. In addition, each restricted licensee must provide a statement signed by a controlling person that the licensee has employed no more than 40 leased employees in South Carolina during the preceding quarter. 4. Service Agreement Please submit a copy of your master service agreement, plus copies of all agreements with client companies which differ from that master agreement in any substantive respect, highlighting the differences, e.g. if any of the PEOs client companies elect to obtain and be responsible for their own workers compensation or health insurance, the service agreement with that client must clearly demonstrate that intent. In addition, South Carolina law requires an applicant for a PEO license to provide a written explanation of this agreement to each assigned employee by delivering it to the employee personally within ten days after executing the agreement. The explanation must state, substantially, the terms of the agreement between the licensee and the client company and include the same notice that is required to be posted in the client companys place of business by South Carolina 40-68-60 (C). Please provide a copy of this written explanation as an attachment to your application. Controlling Persons, Officers and Directors IMPORTANT: Fill out each section completely. All persons who qualify as a controlling person pursuant to South Carolina Code 40-68-10 (4), as amended, must be listed below. Changes in controlling persons should be reported to the Department within 30 days. Any controlling person(s) not previously licensed in South Carolina must each submit a Controlling Person Application (Form PEO-03) along with a $100 Application Fee. Controlling Person applicants associated with a PEO seeking a restricted license MUST PROVIDE THE EMPLOYMENT INFORMATION REQUESTED ON PAGE 5 OF FORM PEO-03, BUT are exempt from THE TWO year prior experience requirement. SUCH APPLICANTS ARE ALSO EXEMPT FROM the continuing education requirements listed ON PAGE 10 OF FORM PEO-03. Corporations: If the applicant is owned by another corporate entity, please list any officers of the parent firm and the ultimate owners (natural persons) in the tables below that qualify as controlling persons, as defined in South Carolina Code 40-68-10 (4), and attach an organizational chart. Controlling Persons Based on Ownership: Please list the names of all persons or entities who directly or indirectly own, control, hold with the power to vote, or hold proxies representing ten percent (10%) or more of the voting securities of the Applicant. If necessary, attach additional sheet(s) providing the same information requested below. Full Name And AddressDate of Birth (mm-dd-yyyy)% OwnershipSSN #/FEIN * FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       * Compliance Note: The Family Independence Act of 1995 required the South Carolina Department of Social Services Child Enforcement Division (Division) to operate a license revocation program for the purpose of enforcing and establishing child support. In accordance with this Act, South Carolina law ( 20-7-944) requires that all licensing entities submit to the Division licensee data for all new and renewal licenses issued. Therefore, identifying information (i.e., name, social security number and date of birth, etc.) for all controlling persons licensed with this renewal application will be forwarded to the Division upon the issuance of each controlling persons license. Personal information will not be used for any other purpose and is not subject to disclosure under the South Carolina Freedom of Information Act. South Carolina Code 30-4-10 et seq Officers, Directors and Controlling Persons Based on Position: Please list the names and titles/positions of all officers, directors and any person who is a controlling person based on their position with the Applicant. If necessary, attach additional sheet(s) providing the same information requested below. Full Name And AddressTitle/PositionDate of Birth (mm-dd-yyyy)SSN # FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Applicant Business History If any question is answered Yes, please attach separate page(s) detailing the circumstances (including any applicable details such as state, license number, dates, etc.) 1. Have any of the Applicants existing or proposed controlling persons been convicted or found guilty of any misdemeanors or felonies (with the exception of minor traffic violations) in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2. 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FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. Has either the Applicant or any of its existing or proposed controlling persons had a license revoked, suspended, or otherwise acted against (including probation, fine, or reprimand) in a disciplinary action in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4. Has either the Applicant or any of its existing or proposed controlling persons been involved in or owned an interest in a PEO or PEO group that has been adjudicated bankrupt, filed proceedings under the Bankruptcy Act, or has otherwise closed due to insolvency?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. Are any of the licenses, registrations, or certifications of the Applicant or any of its existing or proposed controlling persons currently under investigation or currently pending disciplinary action in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 6. Has the Applicant or any of its existing or proposed controlling persons ever failed to satisfy any tax liabilities?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 7. Has the Applicant or any of its existing or proposed controlling persons ever had a lien or levy placed against it/them?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 8. Has the Applicant or any of its existing or proposed controlling persons been the subject of an indictment or a cease and desist order in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 9. Has the Applicant or any of its existing or proposed controlling persons been the subject of any state or federal government investigation or audit regarding the payment of wages or taxes; the funding or administration of any employee benefit plan or workers compensation program; employment practices; licensing or registration; or any other matter arising out of a complaint filed by an employee, client, insurer, regulator or another PEO?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Has the Applicant or any of its existing or proposed controlling persons ever been the subject of a governmental investigation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11. Is the Applicant or any of its existing or proposed controlling persons currently disputing any material obligations to an insurance carrier, benefit administrator or trust, or taxing authority?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 12. Is there any litigation or legal proceeding currently pending or threatened against the Applicant or any of its existing or proposed controlling persons in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 13. Is the Applicant delinquent, as of the date of application, with respect to any of its obligations of payroll, payroll related taxes, workers compensation insurance or employee benefits in any jurisdiction or territory in the United States?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Affidavit of Applicant I swear or affirm and certify that I have completed and/or reviewed all information on this form and submitted with this Application, and to the best of my knowledge and belief, all information contained herein is true, correct and complete; and that there are no material omissions of fact which would have a bearing upon the South Carolina Department of Consumer Affairs decision to grant the requested license. I further certify that I understand that giving false information constitutes cause for denial or revocation of the application and subjects me to criminal prosecution for perjury. I acknowledge that I have a duty and agree to update and correct this information as it changes.  Signature FORMTEXT      Date FORMTEXT      Type or Print your name and Title  SWORN TO AND SUBSCRIBED before me this ________ day of _____________________, 20______ ________________________________________________ (SEAL) Notary Public For __________________________________ My Commission Expires: _____________________________The completed Application should be submitted to: South Carolina Department of Consumer Affairs Attn: PEO Licensing and Regulation P.O. Box 5757 Columbia, SC 29250-5757 Do not fax this form. 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PEO Restricted License Application SCDCA Form PEO-04 Revised 08/07 Page  PAGE 1 of  NUMPAGES 12 Street Address 3600 Forest Drive Columbia, SC 29204-4006 Mailing Address P.O. 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