APPLICATION - Unemployment Services
|Unemployment Services Free Unemployment Account Evaluation |
| |
| |
|Organization Profile |
|Legal Name | |
|Type of Business ο |ο Partnership |ο Corporation |Date Established | |
|501(c)3 ο Government| | | | |
|Date Established | | | | |
|Address of Business Operation | | |
|City | |State | |Zip | |
|Phone | |Fax | |Email | |
|Description of Applicant’s Operation | |
|Number of employees | |Part time | |Full time | |Number of W-2s last year |
|Contact | |Position | |
| |
|Unemployment Compensation Profile |
|Current Funding Method |ο Paying State Unemployment Tax |ο Reimbursing |Account No. | |
|Current management method for unemployment claims |ο Internal Staff |ο Third Party Administrator |
|If managed externally, please identify your | |
|current administrator/program | |
|Have you experienced any lay-offs or staff reductions in the last 24 months? If so, how |ο Yes |ο No |
|many? | | |
|How many Quit and Discharge claims do you receive each year? | |
|Do you expect any layoffs or to eliminate any positions during the next 12 months? If so, |ο Yes |ο No |
|how many? | | |
| | |
|Please enter the following information: |
|Year |Gross Annual Payroll |Unemployment Tax Rate | |
|Last year | | | |
|Current year | estimated | | |
|Tax paying employers: please provide copies of your three most recent State Unemployment Tax Rate Notices. The information provided on this application form is |
|true, accurate, and complete to the best of my knowledge. I acknowledge that any misrepresentation will result in immediate cancellation of any service or |
|coverage pursuant to the terms of this product for which this application is submitted. This form also serves as a temporary authorization allowing Unemployment |
|Services, Inc. to review employer’s unemployment account with the State tax department. Thank You. |
|Signature | |Name |
|Date | |Title |
| |
|Fax to: |UNEMPLOYMENT SERVICES, INC. |1401 Glengary Road, Wolverine Lake, MI 48390 |
| | |Phone: 248-926-8900 |
| | |Fax back to: 248-926-8902 |
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