"Initial Professional Employer Organization Application for Licensure" - Montana

Initial 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.

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  • Released on November 1, 2021;
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INITIAL
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
INITIAL
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):
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
PROFESSIONAL EMPLOYER ORGANIZATION OR GROUP
LICENSE APPLICATION in MONTANA
The Department desires to provide courteous and timely service to all applicants. In order to
maximize efficiency, the Department will process complete applications only. Please read the
instructions carefully to ensure proper completion of the application. In order to become licensed,
you must submit a completed application, which includes all necessary supporting documents
and a non-refundable application fee. The application fee is $750 for a resident or nonresident
unrestricted license, or $500 for a restricted license.
Application: Failure to supply necessary information may result in delay of approval or denial of
your application. An applicant is ineligible to reapply for a license for 1 year following final
department action denying the issuance of or renewal of a license.
Basic Qualifications:
An individual applicant must be at least 18 years of age.
The applicant and each controlling person must be of good moral character, have business
integrity, and be financially responsible.
A “controlling person” means an individual who
possesses the right to direct the management or policies of a professional employer organization
or group through ownership of voting securities, by contract or otherwise.
Ability to maintain a positive working capital.
Nonresidents who want to apply for an unrestricted license must also be licensed by the state of
domicile if PEO or group licensing is required in that state.
Resident or nonresident unrestricted license applicants must show a tangible accounting net worth
of at least $50,000. If an applicant is unable to meet the $50,000 net worth requirement, the
applicant shall provide to the department a surety bond, a letter of credit, or marketable securities
acceptable to the department in an amount of not less than $50,000 to cover the deficiency.
Restricted licenses for PEOs or groups residing in another state may be issued if:
• the applicant’s state of residence licenses PEO’s and the applicant is licensed and in good
standing, and that state grants a similar privilege for restricted licensing;
• applicant does not maintain an office, sales force, or a sales representative in Montana
and does not solicit clients who are residents of or domiciled in Montana; and
• applicant does not have more than 100 leased employees working in Montana.
WORKER’S COMPENSATION REQUIREMENT: All operations of a client, whether or not all or
a portion of the client’s operations are subject to a professional employer arrangement or
employee leasing arrangement, must be insured by the same insurer.
The workers’
compensation insurer is required to report to the workers’ compensation advisory or rating
organization, all data by client including payroll by classification and liabilities for each client during
the term of the policy. The insurer is required to audit policies issued to a PEO within 90 days of
the policy effective date and may conduct quarterly audits thereafter.
Revision 11/1/2021
Please submit each of the following documents and use this checklist for reference:
____ Financial Statements-Pursuant to 39-8-202 (6)(a) Montana Code Annotated (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
____ Attestation of Financial Statement (reference 39-8-202 (6)(c)(ii) MCA)
____ File required documents with MT Secretary of State (reference 39-8-202 (4) (b)-(d) MCA)
Business Services Bureau (406) 444-3665 for questions and/or complete appropriate forms found on website.
http://sos.mt.gov/Business/Forms/
____ MT Identification Number (Withholding Tax) (reference 39-8-207 (4)(a) MCA) contact: MT Department of Revenue
(406) 444-6900 for questions, use their website to register online or print a form.
https://tap.dor.mt.gov/_/#1
____ State Unemployment Tax Account (SUTA) (reference 39-8-207 (4)(b) MCA) contact: MT Department of Labor and
Industry/Unemployment Insurance 1-800-550-1513 for questions and/or use this website to register or print a form.
https://uieservices.mt.gov/_/
____ Independent CPA quarterly submissions demonstrating all payroll-related taxes have been paid.
(reference 39-8-207 (2)(b) MCA)
____ Proof of workers’ compensation for each client company. If no clients, provide MT endorsed master policy.
(reference 39-8-207 (4)(c) MCA)
____ PEO Ownership Information form (reference 39-8-202 (4) MCA)
____ PEO Group Guaranty form (reference 39-8-202 (4)(e) MCA)
____ List of Branch Offices (reference 39-8-202 (5)(a)(i) MCA)
____ Business Operational History (reference 39-8-202 (5)(a)(ii) MCA)
____ Applicant Authorization for Release of Information form (reference 39-8-202 (5)(a)(iii) MCA)
____ Declaration of Accuracy form (reference 39-8-202 (5)(a)(iii) MCA)
____ Client Contract Agreement (reference 39-8-207 (1) MCA)
____ Employee Disclosure (reference 39-8-207 (2)(a) MCA)
____ State of Montana Professional Employer Organization Client Initiation or Termination Form
____ Benefit Program Information (reference 39-8-207 (6) MCA) Summary of Benefits is sufficient
Control Persons
(reference 39-8-102 (3) & 39-8-202 (5)(b)(c) MCA)
____ Applicant/Controlling Person(s) Information form (must complete for each person)
____ Applicant/Controlling Person Questionnaire form (must complete for each person)
____ Controlling Person Authorization for Release of Information form (must complete for each person)
____ Character Reference Affidavit form (must be notarized and completed for each person)
____ Complete a FBI fingerprint card for each control person (request cards from the Department of Labor/ERD).
____ Remittance in the amount of $30 payable to: Montana Criminal Records for each set of fingerprint cards.
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
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