DOL Form EL-1 Employee Leasing Company Licensure & Registration Application - Vermont

Form EL-1 or the "Employee Leasing Company Licensure & Registration Application" is a form issued by the Vermont Department of Labor.

Download a PDF version of the Form EL-1 down below or find it on the Vermont Department of Labor Forms website.

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Vermont Department of Labor
VERMONT
Attn: Employee Leasing Program
P.O. Box 488
Department of Labor
Montpelier, VT 05601-0488
Employee Leasing Company Licensure & Registration Application
Registration information:
Company Name __________________________________________ Fed ID: ______________________
Mailing Address: _______________________________________________________________________
Street Address: _______________________________________________________________________
City _________________________
State __________________ Zip Code ______________________
Email Address: ________________________________________________________________________
Telephone #: _______________________________
Fax #: __________________________________
Address of Vermont office or Name and Address of Vermont Agent (If different from above.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Email Address: _________________________________
Telephone #: _____________________________ Fax #: ______________________________
Contact person for Unemployment Insurance Matters
Name: _______________________________ Telephone #: ______________________________
Please list all individuals who are authorized to enter into contracts on behalf of the employee leasing
company. (Each individual indicated below is required to sign a "Authorizing Individual Affidavit", EL-5 form.)
Name:
Title:
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
Account information:
Please answer the following questions:
1. Do you have your own employees in the State of Vermont?
Yes (proceed to item 2)
No (proceed to Certification and Requirements section)
2. Are you registered as an employer for Unemployment Compensation purposes in Vermont?
Yes (proceed to item 3)
No (proceed to item 4)
3. Indicate your Vermont Department of Labor employer number here: ________________. Proceed to
Certification and Requirements section.
4. If you have not already been assigned a Vermont Department of Labor employer number, you must
complete and return an Employer Registration "Status Report", form C-1.
Page 1 of 2
EL-1 (11/05)
Vermont Department of Labor
VERMONT
Attn: Employee Leasing Program
P.O. Box 488
Department of Labor
Montpelier, VT 05601-0488
Employee Leasing Company Licensure & Registration Application
Registration information:
Company Name __________________________________________ Fed ID: ______________________
Mailing Address: _______________________________________________________________________
Street Address: _______________________________________________________________________
City _________________________
State __________________ Zip Code ______________________
Email Address: ________________________________________________________________________
Telephone #: _______________________________
Fax #: __________________________________
Address of Vermont office or Name and Address of Vermont Agent (If different from above.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Email Address: _________________________________
Telephone #: _____________________________ Fax #: ______________________________
Contact person for Unemployment Insurance Matters
Name: _______________________________ Telephone #: ______________________________
Please list all individuals who are authorized to enter into contracts on behalf of the employee leasing
company. (Each individual indicated below is required to sign a "Authorizing Individual Affidavit", EL-5 form.)
Name:
Title:
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
Account information:
Please answer the following questions:
1. Do you have your own employees in the State of Vermont?
Yes (proceed to item 2)
No (proceed to Certification and Requirements section)
2. Are you registered as an employer for Unemployment Compensation purposes in Vermont?
Yes (proceed to item 3)
No (proceed to item 4)
3. Indicate your Vermont Department of Labor employer number here: ________________. Proceed to
Certification and Requirements section.
4. If you have not already been assigned a Vermont Department of Labor employer number, you must
complete and return an Employer Registration "Status Report", form C-1.
Page 1 of 2
EL-1 (11/05)
Certification and Requirements
u The company certifies that we do not conduct a temporary help business through the same entity as the
employee leasing business.
u The company agrees to maintain separate records for each client company and file reports as required by
law for each of our client companies as required under 1033(4)(B) of Title 21.
u The company agrees to pay unemployment contributions and workers' compensation premiums based on
the experience rating of each client company as required under 1033(4)(C) of Title 21.
u The company acknowledges our joint and several liability with each client company to protect the health,
safety or welfare of an individual leased to a client company.
u The company will attach an audited financial statement and evidence that it has deposited securities or
posted a bond in an amount not less than $100,000.00 or 5 percent of liabilities, whichever is greater as
required under 1033(7) of Title 21. The financial statement shall have been prepared within six months of
the date of application by an independent certified public accountant licensed in this state pursuant to 21
V.S.A 1035 (a).
u The company agrees that the commissioner may liquidate any securities or bond provided upon our
default in paying wages, benefits, workers' compensation premiums or awards of unemployment
compensation premiums.
u The company agrees to adhere to "Unemployment Insurance Requirements" as indicated on enclosed
form EL-5.
By signature below, I certify that the foregoing information is true and accurate.
________________________________
______________________________
Applicant or authorized agent
Date
Page 2 of 2

Download DOL Form EL-1 Employee Leasing Company Licensure & Registration Application - Vermont

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