New Client Setup Form
Company Name:______________________________________________________________
D.B.A.:________________________________________________________________________
Fed ID#:_____________________________ State Tax ID #: __________________________
SUTA#:______________________________
SUTA Rate: ______________________________
Phone: ______________________________ Fax: ___________________________________
President/Owner: __________________ Email Address: _____________________________
Payroll Contact: ___________________ Email Address: _____________________________
Physical Address _________________________City ____________ State____Zip_______
Mailing Address _________________________City_____________ State____Zip_______
First Processing Date: _____________________
First Pay Period: ________________ to _______________
First Check Date: ____________________
Employees Paid: WEEKLY BIWEEKLY SEMI-MONTHLY
Total employees _______ Full Time: ________ Part-Time: ________ 1099:________
Bank information (please include a VOIDED CHECK):
Bank name:_______________________________________________________________
Routing Number:___________________________________________________________
Account Number:__________________________________________________________
Checklist for Implementation of Payroll Services:
o Current Payroll Invoice/Register including Employee Earnings YTD
o Any quarterly report filed in current year prior to start date with IPA
o Employee Information including: Name, Address, City, State, ZIP, SSN, Phone #,
Withholdings/Allowances, Marital Status, Date of Hire, Date of Birth
o Employee Pay Information (Salary or Hourly Rate information)
o Child Support Orders (if needed)
o Proof of FEIN (941 Quarterly Report or any documentation from IRS reflecting FEIN)
Client Signature & Title________________________________ Date__________________
Company Name__________________________________________________________
Authorization to Debit (payroll fees)
I hereby authorize Reliable Premium Management dba Insight Payroll Associates to deduct my payroll fees
from my checking account on a weekly or bi-weekly basis depending upon my payroll frequency. I
understand that the debit will occur as a 1099 payment directly to Insight Payroll Associates from my bank
account listed on this agreement. The amount debited will be varied based on number of employees paid on
payroll and fees incurred by Insight Payroll Associates while managing this payroll account. You will be notified
prior to the ACH for charges outside of the normal per payroll fee.
I acknowledge that I am giving valid bank account information, that I do own it, and that I will maintain
sufficient funds in this account to allow the payroll debits to clear on the applicable dates. Upon receipt of the
ACH debit transfer, I agree and recognize that all deposits paid are due and any transactions reversed or
omitted will incur additional charges. I realize that I am subject to a $25 overdraft fee if items are returned for
insufficient funds. This authorization shall remain in full force and effect until a written ACH termination notice is
received; such written notice must be received at least 10 days prior to the requested termination date.
My payroll invoice per pay period will be as follows (based on number of employees paid)
Payroll Setup/Implementation fee _____________
FOR WEEKLY PAYROLL:
Approx. number of Employees __________
Price per pay period______________
FOR BI-WEEKLY/Bi-MONTHLY PAYROLL:
Approx. number of Employees __________
Price per pay period______________
Service Agreement Terms:
By signing this agreement I am authorizing and engaging Insight Payroll Associates to provide customer support
for payroll and other services I have chosen. I am engaging Insight Payroll Associates to act as a third party
administrator for implementation and on-going support when working with payroll and other service providers. I
acknowledge that Insight Payroll Associates is unable to provide tax or legal advice and that I should contact a
CPA or legal professional for such advice. I understand that it is MY responsibility to review all information in the
payroll system and to review my payroll data prior to processing payroll to ensure accuracy. If Insight Payroll
Associates provides assistance in entering information into the payroll system I agree to review the information
immediately after completion to ensure accuracy and avoid errors. I further agree to notify Insight Payroll
Associates or my payroll provider promptly of any errors in the payroll system so that they can be corrected.
BY SIGNING THIS AGREEMENT, I AUTHORIZE INSIGHT PAYROLL ASSOCIATES TO ACH DEBIT MY ACCOUNT FOR
SERVICE FEES AND AGREE TO THE TERMS ABOVE.
Client Signature and Title___________________________________________Date__________________
Payroll Fee Schedule
ONE-TIME
IMPLEMENTATION FEE
$225
WEEKLY FEE
PER PAY PERIOD
BI-WEEKLY FEE
PER PAY PERIOD
1-5 EMPLOYEES
$44.95
$89.90
6-10 EMPLOYEES
$54.95
$109.90
11-20 EMPLOYEES
$59.95
$119.90
21-30 EMPLOYEES
$69.95
$139.90
31-40 EMPLOYEES
$79.95
$159.90
41-50 EMPLOYEES
$89.95
$179.90
51-60 EMPLOYEES
$99.95
$199.90
All-Inclusive Payroll Package Includes:
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Access to reporting payroll online through a user-friendly site
Option to email, phone in, or fax in payroll per pay period
Online Access to Payroll Check Register & Cash Requirements Statement
Quarterly Federal/State Tax Filing and Depositing (940,941,FUTA,SUTA)
Year-End W-2’s & Tax Filing
General Ledger Posting Report – integration with accounting software
New Hire Reporting
Direct Deposit or Pay Cards
Vacation/Sick/PTO Accruals
Pay-As-You-Go Workers’ Compensation Calculation & Remittal
Garnishment Services
WORKERS’ COMPENSATION
Reliable Premium Management Inc.
Email: [email protected]
Phone – (888)731-8703 / Fax - (866)731-8703
PAY-AS-YOU-GO FORM
Authorization for Third-Party Remit (Insight Payroll Associates Accounts)
I, ______________________________________, acting as _______________________ of __________________________________________,
Name
Title
Company
authorize Reliable Premium Management (RPM) to automatically deduct payments to escrow for the payment
of workers’ comp to my Insurance Carrier. I understand that I will be notified via phone, fax, or email prior to any
charges being withdrawn from my account. My contact preference is (Please “X” one & provide your information):
____Phone #_______________________
____Fax #___________________________
____Email:_______________________________
I hereby authorize the use of the following checking account for automatic withdrawals of my work comp
premium payments.
Name of Financial Institution: __________________________________________
9-digit Bank Routing #: _____________________________Checking Account #: _____________________________________
** PLEASE ATTACH A VOIDED CHECK **
I understand that my work comp premium payments will be collected on a per pay-period basis based upon the
payroll that I submit to Insight Payroll Associates. I understand that the Monday following my check date, I will
receive an email, fax, or phone call from RPM with my work comp premium total. My work comp premium
payment will be deducted from my checking account the Wednesday following my check date.
I understand that the limit of authority given to RPM is only to deduct & remit payments received for the above
named recipient. It is my responsibility to ensure funds are available at the time of draft, and I understand RPM
is not responsible to make payment on my behalf if funds are not available. Should a check be returned unpaid, a
$40 overdraft fee will be assessed. This amount may change without further notice.
I understand that being a part of the pay-as-you-go program means that I will run payroll on a weekly or biweekly basis. If no payroll is posted, I understand that it is the responsibility of RPM to notify the carrier of this.
___________________________________________
Signed
__________________________
Date
___________________________________________
Printed
Disclaimer: RPM is not responsible for any balances due upon completion of a work comp audit by the insurance carrier.
Internal use only (to be completed by the Payroll Rep or the Agent)
Name of Servicing Insurance Agent: ____________________________________ Agency:____________________________
Phone _____________________________ Fax ________________________________ Email __________________________
Name of Payroll Rep: ___________________________________________________________
Cell: _____________________________Note
to Payroll Rep: Please verify that each employee is classified by departmental/workers’ compensation code. Additional employees and/or codes
will be handled by RPM and the Servicing Agent.