Certification of Compliance by the Applicant and an Approved Assurance Organization

The above named employee-leasing company (“Applicant”) requests the above named assurance organization (“Assurance Organization”) to assist Applicant in complying with certification requirements of the Connecticut Wage and Workplace Standards Division under Section 31-221a et seq. of the Connecticut General Statutes.

THE ASSURANCE ORGANIZATION IS HEREBY AUTHORIZED to release to the Division confidential information on behalf of Applicant in support of initial and renewal certification as required by the Division, including but not limited to the following information to be made available to duly authorized Division personnel through secure Internet access
(hereinafter collectively the “Release”):

1. Applicant information - PEO-1

2. Financial information

- Most recent FYE audited financial statements

- Spreadsheet showing prior FYE audited financial information and quarterly updates for most recent five calendar quarters, if available, including current assets & liabilities, net worth, net worth ratio, liquidity ratios (one-year and 90-day) and net income for each period.

- Quarterly certifications by an independent CPA of the timely payment of state and federal payroll taxes, insurance premiums, and contributions to employee retirement plans for most recent calendar quarter and prior five calendar quarters, if available.

3. Insurance information
- Workers’ Compensation information
- Health insurance information

4. Assurance Organization’s certification of applicant’s continuing compliance

This release authorization shall apply to acts by Assurance Organization, its agents, employees, and other designated representatives who provide confidential information to the Division as part of this application and subsequent compliance reporting as required by the Division. Applicant on behalf of itself, its controlling persons, officers, directors, employees and agents, hereby indemnifies and holds harmless the Assurance Organization and its agents, employees, and other designated representatives from any and all claims or damages that may arise as a result of the release of information about Applicant or its controlling persons to the Division.

THE DIVISION IS HEREBY AUTHORIZED to accept information provided by Assurance Organization for annual certification of applicant as required by Public Act 08-105.

I hereby certify, under penalty of perjury, that the above-named Applicant is in full and complete compliance with all requirements for certifications under Public Act 08-105 and that all of the information submitted in this Application and all of the information provided to the Assurance Organization for compliance with its standards and procedures is true and complete. I am aware that submitting late or false information or omitting pertinent or other material information in connection with this application is grounds for denial or revocation of certification and may subject me to civil or criminal penalties. I further certify that I grant permission to the Department of Labor and Assurance Organization to verify information with any federal, state, or local government agency, current or former employer, or insurance company.

WITNESS THE SIGNATURE of Applicant’s duly authorized representative who on behalf of Applicant hereby agrees with and consents to be bound by the provisions of this application:

Assurance Organization does hereby certify that Applicant is in compliance with Assurance Organization’s standards and procedures, which meet the requirements of Public Act 08-105. Such certification shall be continuous and ongoing until Assurance Organization notifies the Division in writing within five business days of a termination of compliance certification.

WITNESS THE SIGNATURE of Assurance Organization’s duly authorized representative who on behalf of Assurance Organization hereby agrees with and consents to be bound by the provisions of this application.