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Client Name Page 1 PEO074 07/16
Office/Client Number
New Employee Packet
Employer Information: Choose your option for submitting employee information. For detailed instructions for these options, refer to the PEO New Employee Packet Employer Instructions. Option 1 - Spreadsheet Submission and Certification (Complete one spreadsheet attachment per client code)
(Requires Authorized Signature in Section A) Option 2 – NEP Submission: Complete B1 and B2 Option 3 – Online payroll clients only: Print out online payroll summary information for applicable new employee in place of completing
Section B1 (Click here for sample online payroll summary.)
A - EMPLOYEE INFORMATION SUBMISSION AND CERTIFICATION
As an authorized representative, I am electing to submit all required new employee information via the approved spreadsheet or through a printout of the online payroll summary information. I attest that I have accurately and completely provided all required information and understand that Paychex Business Solutions (PBS) is relying on the accuracy and completeness of the information provided. I further understand that this information will be the basis upon which PBS sets up each employee and I accept responsibility for any incorrect or inaccurate information provided to PBS.
Client Authorized Signature Signature Title Date
B1 - CORPORATE INFORMATION COMPLETED BY MANAGER OR SUPERVISOR
Client Name
Employee Name
Employee ID
Department Name or Number
Last four digits of Social Security Number
Work Authorization Expiration (if applicable) _/ _/
Employee Worksite Location (full address required)
Address City State Zip Status Full-time Part-time Rate of Pay 1 $ Rate of Pay 2 $ Rate of Pay 3 $
per hour period (select one) per hour period (select one) per hour period (select one)
Gender Female Male Hire Date
Withholding State State Unemployment Insurance State
Job Title Workers’ Comp Class Code
Location Name _______ Insurance Standard Hours ___ Job Category (select one)
Union Employee Yes No
Residence State
Benefit Insurance Class Code
Executive/Senior Level Officials and Managers [1.1] First/Mid-Level Officials and Managers [1.2] Professionals [2] Technicians [3] Sales Workers [4] Office and Clerical [5] Craft Workers (skilled) [6] Operatives (semi-skilled) [7] Laborers (unskilled) [8] Service Workers [9]
Description of Duties (provide a short description of daily regular activities)
Work from remote office or location (note how often)
Travel (note how often)
Supervisor, Manager, or Authorized Signature
Signature Title Date
B2 - EQUAL EMPLOYMENT OPPORTUNITY INFORMATION* We are subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, you must complete the Job Category information. Although employees are invited to voluntarily self- identify their race and ethnicity, submission of this information is voluntary and refusal to provide it cannot and will not subject an employee to any adverse treatment. Because not all employees complete the requested information, you are being asked to do so by conducting a visual assessment of the employee’s National Origin/Race. *Verify Employer and Employee Sections’ information and complete Section 3, if applicable.
Client Name Page 2 PEO074 07/16
New Employee Packet
Employee •Read Sections 1 and 2 •Complete and sign Employee Signature section •Complete Section 3
For all employees:
SECTION 1. EMPLOYEE ACKNOWLEDGEMENTS
I understand that my worksite employer (“Client”) has entered into a Client Service Agreement (“Agreement”) with Paychex Business Solutions or an affiliated company (“PBS”) whereby PBS has agreed to co-employ individuals who are performing services for Client. I understand that I am a co- employee of PBS who will be assigned to perform services for the Client in connection with the Agreement. I understand this relationship may be terminated at will at anytime by me, Client, or PBS. I acknowledge that in the event Client does not pay PBS with respect to the services provided by me to Client for any particular pay period, PBS, where required by law, will pay me for such pay period, and where permitted by law, will pay me the then current minimum wage rate for that pay period and my applicable overtime pay based on such minimum wage rate for that pay period, or the minimum salary for that pay period. In the event that Client files a petition in bankruptcy at a time when monies are due to PBS from Client for wages paid to me, I hereby assign PBS any and all rights I have to assert a priority wage claim in the bankruptcy proceeding. I understand that a mark in the foregoing box constitutes written notice that my worksite employer is providing my workers’ compensation insurance benefits. I understand that PBS is committed to compliance with any and all state and federal Workers’ Compensation laws and requirements. I understand that any special rules and regulations required by my state and/or industry will be posted by Client on the company bulletin boards and/or are available from management for my information and review. I agree to comply with these rules and regulations and realize that failure to do so may affect the benefits provided to me. I understand that, as a newly hired employee of Client or PBS, where permitted by law, I will be subject to an Introductory/Probationary Period for purposes of unemployment insurance. For employees who are not represented by a union: I acknowledge receipt of the Employee Handbook and addenda (if applicable), and I understand that I am responsible for understanding and reviewing the policies contained in that booklet and any subsequent additions, revisions, and/or addenda. I understand that Client may now have, or may establish, a drug-free workplace or a drug and/or alcohol testing program consistent with applicable federal, state, and local law. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state, and local law. I also understand that all employees at the location, pursuant to Client’s policy and federal, state, and local law, may be subject to urinalysis and/or blood screening or other medically recognized tests designed to detect the presence of alcohol or controlled drugs. I understand that the taking of such alcohol and/or drug tests is a condition of continual employment, and I agree to undergo alcohol and drug testing consistent with Client’s policies and applicable federal, state, and local law. I certify that all the information on this document, or any supporting documents is correct, and I understand that any misrepresentation or omission of any information may result in the immediate dismissal of employment. I understand Client and PBS hire only individuals who are legally eligible to work in the United States. If I will be assigned to a work site in Alabama, Montana, South Carolina, or Utah, I recognize that I must review and sign a state-specific Addendum to this New Employee Packet.
SECTION 2. ACKNOWLEDGEMENT OF GROUP BENEFITS (if applicable)
I understand that I may be eligible or become eligible for certain benefits under the group plans provided by Paychex Business Solutions (PBS). Furthermore, I understand in order for my benefits to be effective, I must complete my assigned benefit waiting period and submit the required enrollment forms/correspondence to PBS prior to my effective date of coverage. I acknowledge that it is my responsibility, and/or appropriate family member(s) to read and understand the various benefit plans presented to me in my benefit packet. I also understand that I should refer to the certificates of insurance and/or plan documents for detailed information regarding benefit provisions and that the provisions may be subject to change. I understand that if I enroll, my benefit choices must remain in effect until the following annual enrollment unless I experience a qualifying event as discussed below. I understand that if I do not receive my benefit packet during my benefit waiting period, I am responsible for notifying PBS’ Benefits Department prior to my effective date of coverage. If I am uncertain of my assigned benefit waiting period, I understand I am responsible for obtaining confirmation of my assigned benefit waiting period from my on-site contact or PBS’ Benefits Department. Furthermore, I understand that if I do not return my signed enrollment form to PBS after I begin working as an eligible employee and before the date my coverage is to be effective, PBS will consider this a waiver of group coverage. I understand that if I do not elect benefits at the time of my initial eligibility, I will not be permitted to enroll or make mid-year election changes unless a qualifying event occurs. I understand if I experience a qualifying event and would like to enroll, I must notify PBS and submit the required forms and documentation within 30 days of my qualifying event or I will not be permitted to make changes or enroll until the following annual enrollment. Furthermore, I understand if I request coverage for myself and eligible dependents as a late enrollee and am accepted, I will be required to furnish evidence of good health for each individual (“Certificates of Creditable Coverage”), or be subjected to the insurance policies pre-existing exclusion provisions. I authorize deductions for required employee contributions toward group benefits. I understand that in the event my employment terminates in the middle of a month, the medical, dental and/or vision plan I elected will continue until the end of that month, and any Flexible Savings Account Plan, Short-Term Disability or Long-Term Disability plan elected will terminate concurrently with my termination from employment. I authorize PBS to deduct from my final paycheck, as authorized by state and federal law, the full employee contribution payments owed for the final month of the applicable group benefits. I understand that I must meet the eligibility requirements for coverage to be effective.
EMPLOYEE SIGNATURE
Name Social Security Number - -
Address City State Zip
Telephone Number ( ) -
Birth Date I have read and acknowledge all of the statements contained in Section 1 (“Employee Acknowledgements”) and in Section 2 (“Acknowledgement of Group Benefits”) of this New Employee Packet.
Signature Date Continue to Section 3
New Employee Packet
Client Name Page 3 PEO074 07/16
Employee •Read Sections 1 and 2 •Complete and sign Employee Signature section •Complete Section 3
Employee Name
SECTION 3. EQUAL EMPLOYMENT OPPORTUNITY INFORMATION We are subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite you to voluntarily self-identify your race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify specific individuals.
A visual assessment of the employee’s National Origin/Race has been made as the employee has not voluntarily provided this information.
Gender Female Male National Origin (if you meet the definition of Hispanic or Latino, check the box below.) Hispanic or Latino (All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of
race.) Race (check the appropriate box) White (Not of Hispanic or Latino origin. All persons having
origins in any of the original peoples of Europe, North Africa, or the Middle East.)
Black or African American (Not of Hispanic or Latino origin. All persons having origins in any of the Black racial groups of Africa.)
Asian (Not of Hispanic or Latino origin. All persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent.)
Native Hawaiian or Other Pacific Islander (Not of Hispanic or Latino origin. All persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
American Indian or Alaskan Native (Not of Hispanic or Latino origin. All persons having origins in any of the original peoples of North and South America, and who maintains tribal affiliation or community attachment.)
Two or More Races (Not of Hispanic or Latino origin. All persons who identify with more than one of the five races listed.)
Employee’s Personal Email Address Employee’s Work Email Address Mail or fax to:
970 Lake Carillon Drive, Suite 400 Fax: 1-800-668-7296 St. Petersburg, FL 33716
Internal Use Only
Underwriting Audit Updates
Workers’ Comp Class Code
Benefit Insurance Class Code
Audit completed by
Payroll Audit
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DP0002 10/17 Form Expires 10/31/20
Direct Deposit Enrollment/Change Form*
Company Name and/or Client Number ________________________________________________________
Employee/Worker Name_____________________________ Employee/Worker Number __________
EMPLOYEE/WORKER: Retain a copy of this form for your records. Return the original to your employer/company.
EMPLOYER/COMPANY: Return this form to your local Paychex office. For clients using on-line services, please retain a copy of this document for your records.
COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS –
PLEASE PRINT CLEARLY IN BLACK/BLUE INK ONLY
Routing/Transit Number
Checking/Savings
Account Number**
(“Bank”) Name
I wish to deposit (check one):
Checking Savings
_____
% of Net
Specific Dollar Amount $
Remainder of Net Pay
Checking Savings
_____
% of Net
Remainder of Net Pay
COMPLETE IF
CHANGING EXISTING DEPOSIT AMOUNTS –
PLEASE PRINT CLEARLY IN BLACK/BLUE INK ONLY
From _____% to____% of Net From $ ______ .00 To $_____.00 Remainder of Net Pay
I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions processed by Paychex, Inc. I have reviewed the information provided and it is accurate to the best of my knowledge. My signature below indicatesthat I have the authority to execute this document on behalf of the Client.
Employer/Company Representative Printed Name: ________________________________ Employer/Company Representative Signature:_____________________________________
Date: _______________
EMPLOYEE/WORKER CONFIRMATION STATEMENT
PLEASE SIGN IN BLACK/BLUE INK ONLY I authorize my employer/company to deposit my earnings into the bank account(s) specified above and, if necessary, to electronically debit my account to correct erroneous entries. I certify my account(s) allow these transactions. Furthermore, I certify that the above listed account number accurately reflects my intended receiving account. I agree that direct deposit transactions I authorize comply with all applicable laws. My signature below indicates that I am agreeing that I am either the accountholder or have the authority of the accountholder to authorize my employer/company to make direct deposits into the named account.
Employee/Worker Signature ______________________________________ Date ________________
Note:
Digital or Electronic Signatures are not
acceptable.
* All fields are required except Employee/Worker Number. ** Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information specific to your account.
_______________ .00
Type of Account:
Routing/Transit Number
Checking/SavingsAccount Number**
Financial Institution
Financial Institution (“Bank”) Name
I wish to deposit (check one): Specific Dollar Amount $ _______________ .00
Type of Account:
Routing/Transit Number
Checking/SavingsAccount Number**
Financial Institution (“Bank”) Name
I wish to change my deposit amount to (check one):
Type of Account: Accountholder's Name:
Accountholder's Name:
Checking Savings Accountholder's Name:
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A: General Information :
What is the Health Insurance Marketplace?
Can I Save Money on my Health Insurance Premiums in the Marketplace?
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
How Can I Get More Information?
Form Approved OMB No. 1210-0149
5 31 2020
PART B: Information About Health Coverage Offered by Your Employer
3. Employer name 4. Employer Identification Number (EIN)
5. Employer address 6. Employer phone number
7. City 8. State 9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above) 12. Email address
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible inthe next 3 months?
Yes (Continue)13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the
employee eligible for coverage? (mm/dd/yyyy) (Continue)No (STOP and return this form to employee)
14. Does the employer offer a health plan that meets the minimum value standard*?Yes (Go to question 15) No (STOP and return form to employee)
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't includefamily plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ shereceived the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based onwellness programs.a. How much would the employee have to pay in premiums for this plan? $b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
16. What change will the employer make for the new plan year?Employer won't offer health coverageEmployer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect thediscount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan? $b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A: General Information
What is the Health Insurance Marketplace?
Can I Save Money on my Health Insurance Premiums in the Marketplace?
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
How Can I Get More Information?
Form Approved OMB No. 1210-0149
(expires 5-31-2020)
PART B: Information About Health Coverage Offered by Your Employer
3. Employer name 4. Employer Identification Number (EIN)
5. Employer address 6. Employer phone number
7. City 8. State 9. ZIP code
10. Who can we contact at this job?
11. Phone number (if different from above) 12. Email address
