Form DBPR ELC5 "Application for Registration as a Deminimus Employee Leasing Company Group" - Florida

What Is Form DBPR ELC5?

This is a legal form that was released by the Florida Department of Business & Professional Regulation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2013;
  • The latest edition provided by the Florida Department of Business & Professional Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DBPR ELC5 by clicking the link below or browse more documents and templates provided by the Florida Department of Business & Professional Regulation.

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Download Form DBPR ELC5 "Application for Registration as a Deminimus Employee Leasing Company Group" - Florida

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State of Florida
Department of Business and Professional Regulation
Board of Employee Leasing Companies
Application for Registration as a Deminimus Employee Leasing Company Group
Form # DBPR ELC 5
DEMINIMUS EMPLOYEE LEASING COMPANY GROUP QUALIFICATIONS
Two or more, but not more than five, employee leasing companies that are majority owned by
the same ultimate parent, entity, or persons may be licensed as an employee leasing company
group.
Deminimus employee leasing company groups must be domiciled outside of the state of
Florida.
Deminimus employee leasing company groups must be licensed or registered as an employee
leasing company in its state of domicile, if such state requires licensure or registration.
Deminimus employee leasing company groups shall not have client companies who are
domiciled or maintain a principle office located in Florida.
Deminimus employee leasing company groups may not maintain an office located in Florida.
Deminimus employee leasing company groups may not advertise or solicit business in any
manner from clients who are based in or domiciled in Florida.
Deminimus employee leasing company groups may not have more than fifty (50) leased
employees working in the state of Florida.
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION REQUIREMENTS
ALL Employee Leasing Company Group Applicants must submit:
Fees:
• Registration Fee- $500 non-refundable registration fee per employee leasing company group.
• Make all checks payable to the Florida Department of Business and Professional Regulation.
Complete application form # DBPR ELC 5 Application for Registration as a Deminimus Employee
Leasing Company Group.
• Complete Section XII- Historical Sketch, on pages 13-15 of this application packet. Rule 61G7-
5.0012, Florida Administrative Code requires that all applicants complete this form to disclose
individuals who directly or indirectly control a specified percentage of voting stock, and/or are
directors or principal officers of the applicant or its ultimate parent. The following individuals are
required to submit Historical Sketches:
Individuals directly or indirectly controlling 20% or more of the voting stock of the
o
applicant or ultimate parent, if the applicant or its ultimate parent is a publicly traded
company.
Individuals directly or indirectly controlling 10% or more of the voting stock of the
o
applicant or ultimate parent, if the applicant or its ultimate parent is a closely held
company.
All directors or principal officers of the applicant or its ultimate parent.
o
For more information about Historical Sketch reporting requirements see
Rule 61G7-
o
5.0012, Florida Administrative Code.
Make additional copies as necessary.
o
• Complete and sign the Quarterly Compliance Form, Form # DBPR EL 4522, on page 16 of this
application packet.
• Health Insurance Statement (Form # DBPR EL 4507, on page 17 of this application packet)
completed by your insurance provider stating that the plan of insurance is a fully-insured plan. If
the insurance provider refuses to sign the statement, you must provide a complete copy of each
health insurance policy. This is only required if providing health insurance to leased employees.
Submit all required Exhibits and label them according to their exhibit number.
DBPR ELC 5 Registration as a Deminimus Company Group
2013 August
Incorporated by Rule: 61-35.013
1 of 17
State of Florida
Department of Business and Professional Regulation
Board of Employee Leasing Companies
Application for Registration as a Deminimus Employee Leasing Company Group
Form # DBPR ELC 5
DEMINIMUS EMPLOYEE LEASING COMPANY GROUP QUALIFICATIONS
Two or more, but not more than five, employee leasing companies that are majority owned by
the same ultimate parent, entity, or persons may be licensed as an employee leasing company
group.
Deminimus employee leasing company groups must be domiciled outside of the state of
Florida.
Deminimus employee leasing company groups must be licensed or registered as an employee
leasing company in its state of domicile, if such state requires licensure or registration.
Deminimus employee leasing company groups shall not have client companies who are
domiciled or maintain a principle office located in Florida.
Deminimus employee leasing company groups may not maintain an office located in Florida.
Deminimus employee leasing company groups may not advertise or solicit business in any
manner from clients who are based in or domiciled in Florida.
Deminimus employee leasing company groups may not have more than fifty (50) leased
employees working in the state of Florida.
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION REQUIREMENTS
ALL Employee Leasing Company Group Applicants must submit:
Fees:
• Registration Fee- $500 non-refundable registration fee per employee leasing company group.
• Make all checks payable to the Florida Department of Business and Professional Regulation.
Complete application form # DBPR ELC 5 Application for Registration as a Deminimus Employee
Leasing Company Group.
• Complete Section XII- Historical Sketch, on pages 13-15 of this application packet. Rule 61G7-
5.0012, Florida Administrative Code requires that all applicants complete this form to disclose
individuals who directly or indirectly control a specified percentage of voting stock, and/or are
directors or principal officers of the applicant or its ultimate parent. The following individuals are
required to submit Historical Sketches:
Individuals directly or indirectly controlling 20% or more of the voting stock of the
o
applicant or ultimate parent, if the applicant or its ultimate parent is a publicly traded
company.
Individuals directly or indirectly controlling 10% or more of the voting stock of the
o
applicant or ultimate parent, if the applicant or its ultimate parent is a closely held
company.
All directors or principal officers of the applicant or its ultimate parent.
o
For more information about Historical Sketch reporting requirements see
Rule 61G7-
o
5.0012, Florida Administrative Code.
Make additional copies as necessary.
o
• Complete and sign the Quarterly Compliance Form, Form # DBPR EL 4522, on page 16 of this
application packet.
• Health Insurance Statement (Form # DBPR EL 4507, on page 17 of this application packet)
completed by your insurance provider stating that the plan of insurance is a fully-insured plan. If
the insurance provider refuses to sign the statement, you must provide a complete copy of each
health insurance policy. This is only required if providing health insurance to leased employees.
Submit all required Exhibits and label them according to their exhibit number.
DBPR ELC 5 Registration as a Deminimus Company Group
2013 August
Incorporated by Rule: 61-35.013
2 of 17
Required Exhibits: Please attach the following documents and label them as the exhibit numbers
indicated.
Note:
ALL exhibits must be attached or enclosed. If the documents requested in a particular
exhibit do not apply to you, submit a page referencing that exhibit number and include on that
page an explanation as to why the requested information does not apply. Please submit ALL
documentation on 8 ½ x 11 paper.
Exhibit 1: Certificate of Good Standing or Authority from Florida Secretary of State’s office. For
more information on how to obtain this document, contact the Secretary of State, Division of Corporations
at 850.488.9000.
Exhibit 2: Workers’ Compensation Certificate of Insurance (COI). Attach a COI from the workers’
compensation insurance provider for each policy held. The provider must be an admitted carrier in the
State of Florida. The COI must name the employee leasing company as the insured, name the
Board of Employee Leasing Companies (including address) as the certificate holder, include a 30-
day notice of cancellation, bears the signature of an authorized representative of the insurance
provider, and state that it covers all leased employees in this state.
Exhibit 3: Copies of UCT-6 Forms. The UCT-6 form is the Florida Department of Revenue
Employer’s Quarterly Report form. This form will be used to determine the amount of assessment due.
Please attach a copy of the UCT-6 forms filed with the Florida Department of Revenue for the preceding
calendar year. In the event no wages were paid during the preceding calendar year, please provide a
statement from management stating such.
Exhibit 4: State Taxes Letter of Good Standing. Provide documentation from each state as
evidence that payroll taxes, unemployment taxes, etc., are current in those states.
Exhibit 5: State License Letter of Verification/Good Standing. Please submit a letter of
verification/good standing for each state in which you hold a license to practice as an employee leasing
company/group.
Exhibit 6: IRS Form 8821. Complete
IRS Form 8821
for each employee leasing company. Return the
completed form(s) with your application. It may be forwarded to the Internal Revenue Service (IRS) for
processing. The purpose of this form is to determine if there are any delinquent taxes or penalties due
from the employee leasing company.
Complete the following items on the form:
Instructions for completing IRS Form 8821:
Complete the following items on the form:
1. Taxpayer information
This must be the name of the applicant.
o
2. Appointee
This must be named Florida Department of Business and Professional Regulation -
o
Employee Leasing Board, 2601 Blair Stone Road, Tallahassee, Fla. 32399.
3. Tax matters:
The appointee is authorized to inspect and/or receive confidential tax information in any
o
office of the IRS for the tax matters listed on this line. You must list forms 940 and 941 as
well as any additional forms the applicant will be filing.
Year(s) or period(s) must include the current year, past two (2) years and three (3) future
o
tax periods.
4. Complete # 4 specific use not recorded on centralized authorization file.
You must check off # 4 on this section.
o
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. Application Instructions by section
a. Section I- Application Type
i. Select “Applying as a Group Leader” if you will be applying as the group leader.
ii. Select “Applying as Member of a NEW Group License” if you will be applying to form a
new employee leasing company group that has not been previously licensed.
iii. Select “Applying as Member of an Existing Group License” if you will be joining an
existing employee leasing company group. Provide the group license number.
iv. Provide the information for the leader of the employee leasing company group.
b. Section II- Company Information
DBPR ELC 5 Registration as a Deminimus Company Group
2013 August
Incorporated by Rule: 61-35.013
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i. Fill out each section completely.
ii. In the Company Name section, applicants must provide their full legal name as filed
with the Secretary of State, Division of Corporations. Do not use any nicknames,
aliases, or initials.
iii. If your company plans to operate under a fictitious name, list the fictitious name as
listed on the certificate from the Secretary of State’s office that you have been
approved to do business under this name.
iv. A Federal Employer ID Number (FEID) is required in order to apply for a company
license within the Department of Business and Professional Regulation.
v. Provide the Unemployment Tax Identification Number given by the Florida Division of
Unemployment Compensation or the Internal Revenue Service.
vi. Please select the type of business of the employee leasing company
vii. Provide the Corporation Identification Number, Organization Date and Fiscal Year End
of company as listed with the Florida Division of Corporations.
viii. Provide the state of domicile for the company you are registering.
ix. Provide the license or registration number for the company from the state in which it is
domiciled. If the state of domicile does not require licensure or registration, please
enter “Not Required” in this section.
x. Answer whether the company provides leased employees to any clients whose
business is located, domiciled, or has a principle office in Florida.
xi. Answer whether the company maintains an office in Florida.
xii. Answer whether the company solicits clients located or domiciled in Florida.
xiii. Answer whether the company has more than 50 leased employees working in Florida.
xiv. Provide your mailing address. This will be used for sending correspondence regarding
your application and license.
xv. Provide the company location address if different from the mailing address.
xvi. Provide a contact name, valid phone number and email address. Contact information is
often used to quickly resolve questions with applications by telephone call or email. If
contact information is not provided, questions regarding applications will be mailed to
the applicant’s mailing address and may take longer to resolve. Providing your email
address is a public record.
xvii. Provide the Registered Agent information for the company as designated with the
Florida Secretary of State’s office.
c. Section III- Company Ownership
i. Provide the names, addresses, titles, Social Security numbers, and percentage of
ownership which totals 100% of the company’s ownership. Officers, managers, and
controlling persons must also provide this information.
ii. If already licensed as a controlling person, provide the license number. If not, answer if
you will or will not be submitting a controlling person application packet.
d. Section IV- Company Background Information
i. Question 1:
1. (a) If you answer “yes” to this question, you must complete Section V [make
additional copies as necessary] of the application and provide a copy of the
arrest report, copies of the disposition or final order(s), and documentation
proving all sanctions have been served and satisfied. You must supply this
documentation for each occurrence. If you are unable to supply this
documentation, a certified statement from the clerk of court for the relevant
jurisdiction stating the status of records is required.
If you are still on probation, you must supply a letter from your probation officer,
on official letterhead, stating the status of your probation.
2. (b) If you answer “yes” to this question, you must complete Section VI [make
additional copies as necessary] of the application by explaining the nature of the
license, registration or certification refusal.
3. (c) If you answer “yes” to this question, you must complete Section VI [make
additional copies as necessary] of the application by providing an explanation for
the action against your license and supply copies of the order(s) showing the
disciplinary action taken against the license, or documentation showing the
status of the pending action.
4. (d) If you answer “yes” to this question, you must complete Section VI [make
additional copies as necessary] of the application by explaining the nature of the
bankruptcy. If a judgment was entered, please supply documentation proving all
DBPR ELC 5 Registration as a Deminimus Company Group
2013 August
Incorporated by Rule: 61-35.013
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sanctions have been served and satisfied, or if not, stating the current status of
any proceedings.
5. (e) If you answer “yes” to this question, you must complete Section VI [make
additional copies as necessary] of the application by explaining the nature of the
case and the allegations made against the entity you were affiliated with. If a
judgment was entered against the entity, please supply documentation proving
all sanctions have been served and satisfied, or if not, stating the current status
of any proceedings.
ii. Question 2:
1. If you answer “yes” to this question, you must complete Section VI [make
additional copies as necessary] of the application by explaining the reason for
investigation or pending disciplinary action. You may be asked to supply copies
of documentation ordering the investigation or pending disciplinary action.
iii. Question 3:
1. If you answer “yes” to either 3(a) or 3(b) of this question, you must complete
Section VI and VII [make additional copies as necessary] of the application and
provide the information asked in the section.
e. Section V- Explanation(s) for Background Question 1(a)
i. Provide the information requested regarding the offense. Include supporting
documentation as requested in Section III.
f.
Section VI- Explanation(s) for Background Questions 1(b-e) and 2
i. Provide the information requested regarding the occurrence. Include supporting
documentation as requested in Section III.
g. Section VII- Explanation for Background Question 3
i. Provide the information requested regarding your insurance coverage.
h. Section VIII- Health Insurance Information
i. Provide the policy or contract number, name of carrier or service provider, effective
dates of coverage, and name and address of agent if you plan to offer health
insurance, including dental, to leased employees in the state of Florida.
ii. If you answered “yes” to Question 3 (a) or (b) in Section III this must be completed.
i.
Section IX- Workers’ Compensation, Unemployment Compensation, and Payroll Tax
Disclosure
i. Provide information as it relates to obligations for workers’ compensation. This includes
any amounts under dispute.
ii. Provide information about taxes paid to the State of Florida under the unemployment
tax account listed on page three (3) of the application.
j.
Section X – Affirmation by Written Declaration
i. The applicant must sign the affirmation by written declaration.
k. Section XI- Historical Sketch
i. This form must be completed by all individuals who directly or indirectly control a
specified percentage of voting stock, and/or are directors or principal officers of the
applicant or the ultimate parent.
ii. Provide the name, date of birth, social security number, and relationship to the
applicant.
iii. Provide the mailing address of the individual completing the historical sketch form.
iv. Provide a list of all business entities or organizations with which you are presently
affiliated.
v. If you answer “yes” to any of the background questions, you must provide a statement
of the charges and facts for the case, together with the name and location of the courts
in which the proceedings were held or are pending.
vi. Provide a list of each employer within the past four years.
vii. Provide the company name, type of business and address of the employer for which
employment is being provided.
viii. Provide the individual’s title and dates of employment.
-
l.
Section XII
Affirmation by Written Declaration for Historical Sketch
i.
The applicant must sign the affirmation by written declaration.
DBPR ELC 5 Registration as a Deminimus Company Group
2013 August
Incorporated by Rule: 61-35.013
5 of 17
State of Florida
Department of Business and Professional Regulation
Board of Employee Leasing Companies
Application for Registration as a Deminimus Employee Leasing Company Group
Form # DBPR ELC 5
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
For additional information see the Instructions at the beginning of this application.
Section I – Application Type
APPLICATION TYPE
 Applying as a Group Leader [6306/1030]
 Applying as Member of a NEW Group License [6307/1030]
 Applying as Member of an EXISTING Group License: Group License Number: _________[6307/1030]
GROUP LEADER INFORMATION
Group Leader (primary company) Name:
Street Address
City
State
Zip Code
Email Address (optional)
Phone Number
Section II – Company Information
COMPANY INFORMATION
Company Name:
Doing Business As (D/B/A):
Federal Employer ID Number (FEID):
Unemployment Tax Identification Number:
Business Type:  Sole Proprietor
 LLC
 Corporation
Partnership
Other (please specify):
Corporation Identification Number with Florida
Organization Date:
Fiscal Year End:
Division of Corporations:
State of Domicile:
License/Registration Number:
Does Company provide leased employees to a client whose business is located, domiciled, or has a
 Yes
 No
principle office located within Florida?
 Yes
 No
Does Company maintain an office in Florida?
 Yes
 No
Does Company solicit clients located or domiciled in Florida?
 Yes
 No
Does Company have more than 50 leased employees working in Florida?
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code
County (if Florida address)
Country
DBPR ELC 5 Registration as a Deminimus Company Group
2013 August
Incorporated by Rule: 61-35.013