"Renewal Professional Employer Organization Application for Licensure" - Montana

Renewal Professional Employer Organization Application for Licensure is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on November 1, 2021;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

ADVERTISEMENT
ADVERTISEMENT

Download "Renewal Professional Employer Organization Application for Licensure" - Montana

Download PDF

Fill PDF online

Rate (4.4 / 5) 24 votes
RENEWAL
PROFESSIONAL EMPLOYER ORGANIZATION
APPLICATION FOR LICENSURE
MONTANA
The application fee is:
___$750.00 Unrestricted license
___$500.00 Restricted license
Fees Payable To:
Department of Labor and Industry
Employment Relations Division
Mailing Address:
PO Box 8011, Helena MT 59624-8011
Revised 9/29/2006
Street Address:
1315 Lockey Ave, Helena MT 59601
Contact Person:
Amber Weekes, Program Manager
Phone :
(406) 444-7748
Email :
DLIERDPEO@mt.gov
Web Address :
http://erd.dli.mt.gov/work-comp-
regulations/professional-employer-organizations
Revision 11/1/2021
RENEWAL
PROFESSIONAL EMPLOYER ORGANIZATION
APPLICATION FOR LICENSURE
MONTANA
The application fee is:
___$750.00 Unrestricted license
___$500.00 Restricted license
Fees Payable To:
Department of Labor and Industry
Employment Relations Division
Mailing Address:
PO Box 8011, Helena MT 59624-8011
Revised 9/29/2006
Street Address:
1315 Lockey Ave, Helena MT 59601
Contact Person:
Amber Weekes, Program Manager
Phone :
(406) 444-7748
Email :
DLIERDPEO@mt.gov
Web Address :
http://erd.dli.mt.gov/work-comp-
regulations/professional-employer-organizations
Revision 11/1/2021
Important Information
(Must be completed)
Applicant Name(s): ______________________________________________________
FEIN(s) ___________________________
Street and Mailing Address:
Montana Branch Offices
Yes
No
(If yes, attach list of all MT branch locations,
street address and phone number)
Contact Person(s):
Business Phone #
Email(s):
amount of $30 payable to: Montana Criminal Records for each set of fingerprint cards.
State Unemployment Tax Account(s) (SUTA):______________________
Workers’ Compensation Policy Number(s): ________________________
BENEFITS PROGRAMS: A professional employer organization or group shall disclose to
the department, to each client, and to its employees information on any health or life fringe
benefit program provided for its employees.
Are benefits provided ____ Yes ____ No
If yes, please complete the following information or submit as an attachment:
Type of benefits: _____________________________________________
Identity of each Insurer providing coverage: _______________________________________
Amount of benefits for each type of coverage: _____________________________________
Policy limits on each insurance policy: ____________________________________________
Whether coverage is fully insured, partially insured or fully self-funded: ______________
Revision 11/1/2021
CHECKLIST A:
The following supporting documents must be submitted with your application for compliance
with Title 39, Chapter 8 Montana Code Annotated (MCA). Please read the instructions carefully
to ensure proper completion of the application. The non-refundable application fee is $750 for a
resident or nonresident unrestricted license, or $500 for a restricted license.
Financial Statements-Pursuant to 39-8-202 (6)(a) (MCA), Except for an applicant who is granted a
restricted license under subsection (9), an applicant shall maintain a tangible accounting net worth of not
less than $50,000, evidenced by: (i) providing financial statements that have been independently audited
by a certified public accountant in accordance with generally accepted accounting principles; or (ii)
providing independently compiled financial statements and a $100,000 security deposit in a form that
is acceptable to the department. 39-8-202 (7) MCA, The applicant shall maintain a positive working
capital, as evidenced by financial statements (reference
Attestation of Financial Statement (reference 39-8-202 (6)(c)(ii) MCA)
Proof of workers’ compensation for each client company. If no clients, provide MT endorsed master
policy. (reference 39-8-207 (4)(c) MCA) Note: If your insurer provides policies to this office or you
previously submitted policies, please don’t duplicate!
List of Montana Client Companies – (reference 39-8-207 (2)(e) (MCA) currently under contract
with the applicant, including the name of the business, their Federal Employer ID number, business
address, primary business operation and the beginning date of the contract.
Applicant/Controlling Person Questionnaire (reference 39-8-202 (5)(a)(iii) MCA)
Declaration of Accuracy form (reference 39-8-202 (5)(a)(iii) MCA)
Professional Employer Organization Group Guarantee form – if applicable (reference 39-8-202
(4)(e)(iii)
CHECKLIST B:
THE FOLLOWING NEED TO BE SUBMITTED IF CHANGES HAVE OCCURRED OR OCCUR
DURING THE LICENSE YEAR.
Pursuant to 39-8-207(2)(d) MCA Requirements of Licensee The professional employer organization or
group shall: notify the department in writing within 20 days of a change of business address or a change
in partners, directors, officers, members, or controlling persons designated in the license. The following
forms should be used for these changes:
APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION
PEO OWNERSHIP INFORMATION/Business Operational History
APPLICANT/CONTROLLING PERSON INFORMATION SHEET
CONTROLLING PERSON AUTHORIZATION FOR RELEASE OF INFORMATION
CHARACTER REFERENCE AFFADAVIT (needs to be notarized)
Pursuant to 39-8-207(2)(e) MCA Requirements of Licensee The professional employer organization or
group shall: notify the department in writing within 20 days after a client either commences or terminates
a professional employer arrangement or an employee leasing arrangement with that professional
employer organization or group. The following form should be used and can be emailed, once
completed:
Professional Employer Arrangement Client Initiation or Termination Form
Pursuant to 39-8-207(1) (2) MCA Requirements of Licensee A professional employer organization or
group shall, by written contract with the client, establish the responsibilities and duties of each party.
Client contract agreements and or Employee Disclosure
Revision 11/1/2021
STATE OF MONTANA
PROFESSIONAL EMPLOYER ORGANIZATION
CLIENT INITIATION OR TERMINATION FORM
39-8-207 (2)(e) Montana Code Annotated, states the professional employer organization or group shall:
notify the department in writing within 20 days after a client either commences or terminates a professional
employer arrangement or an employee leasing arrangement with that professional employer organization or
group.
Please furnish a copy of this completed form:
Email:
DLIERDPEO@mt.gov
DLI/ERD use only
Mail: State of Montana
Excel: ________________________
Department of Labor & Industry
Policy:________________________
Employment Relations Division
NCCI: ________________________
Attn: Amber Weekes
UI:___________________________
PO Box 8011, Helena MT 59604-8011
UEF Letter: ___________________
1805 Prospect Ave, Helena MT 59601
Notes: _______________________
Phone: 406-444-7748
_____________________________
Professional Employer Organization Information:
Name of Company: ____________________________________________________________
Address of Company: __________________________________________________________
City, State & Zip: ______________________________________________________________
Contact Person: ____________________________________Telephone#_________________
Federal Tax ID # ____________________________________
=====================================================================
Client Company Information:
Name of Client Company: _______________________________________________________
Address of Client Company: _____________________________________________________
City, State & Zip: ______________________________________________________________
Contact Person: _____________________________________Telephone #_______________
Federal Tax ID #: ____________________________
Month, Day and Year leasing arrangement initiated in Montana: ________________________
Month, Day and Year leasing arrangement terminated with PEO: _______________________
If different than term date, please provide the last date of payroll in Montana: _____________
If Montana business address is not a home residence, please provide the MT address (upon termination):
___________________________________________________________________________________
Reason for termination (be specific):_____________________________________________________
Client has terminated with PEO
Client is still active with PEO but no MT employee exposure
WC class codes used for this client: ______________________________________________________
WC policy number: ____________________________Policy effective date: ______________________
Completed by: _______________________________
Date form completed: ______________
Revision 11/1/2021
ATTESTATION OF FINANCIAL STATEMENT
We, the undersigned, in conformance with section 39-8-202, MCA, do hereby attest to the
accuracy and completeness of the financial statements submitted herein and attached hereto by
_____________________________________________ (applicant) as part of the application
process for licensure as a Professional Employer Organization.
attest:______________________________________
_____________
______________________________________
Date
Signature and printed name of applicant president
attest:______________________________________
____________
______________________________________
Signature and printed name of chief financial officer
Date
attest:______________________________________
____________
______________________________________
Date
Signature and printed name of a controlling person
Revision 11/1/2021
Page of 14