STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY
OFFICE OF LABOR COMMISSIONER
1818 COLLEGE PARKWAY, SUITE 102
CARS0N CITY, NEVADA 89706
775-684-1890
3300 WEST SAHARA AVENUE, SUITE 225
LAS VEGAS, NEVADA 89102
702-486-2650
APPLICATION FOR PROFESSIONAL EMPLOYER ORGANIZATION LICENSE
All Questions Must be Answered – Application Must be Completed in either Blue Ink or be Typewritten
*License will expire on September 30. Renewal is incumbent upon the license holder.*
PLEASE SELECT THE PURPOSE OF YOUR APPLICATION:
___-______
New Renewal
License Number: OLC-
Professional Employer Organization License (PEO) for the year ending September 30, 20____
An applicant shall submit to the Labor Commissioner any change in information as required
in NRS 616B.679 within 30 days after the change occurs. The Labor Commissioner
may revoke the certificate of registration of an Professional Employer Organization which
fails to comply with the provisions of NRS 616B.670 to 616B.697, inclusive.
Section A:
Name of Professional Employer Organization (PEO):
FEIN ________________________
Business Address of Professional Employer Organization (PEO) (P.O. Box is NOT acceptable):
Business Telephone:
Business Contact Name and Title:
List the Names of all Owners, Partners, and/or Corporate Officers:
Name
Title
SSN
% of
Ownership
Name
Title
SSN
% of
Ownership
Name
Title
SSN
% of
Ownership
Name
Title
SSN
% of
Ownership
Part #1 – Application and attachments
PEO Registration Fee of $500 (Make check Payable to the Office of the Labor
Commissioner)
PEO Registration Application
Section B - Checklist
Section C – Client Company List. A separate list may be used, however all
information requested must be included in the table.
Section D – Declaration Page. This form MUST be signed by each officer as listed in
the registration application and registered by the Nevada Secretary of State.
Proof of State Business License required by Chapter 76 of the Nevada Revised
Statutes. Please Contact the Nevada Secretary of State for assistance.
http://www.nvsos.gov/index.aspx?page=267.
Acceptable proof is a copy of the Business License Certificate and a printout from the
Nevada Secretary of States website showing current officers/managers/directors.
Part #2 - Insurance Benefit Plans. Pursuant to Title 57 of the Nevada Revised Statutes, a
Professional Employer Organization (PEO) shall not offer its employees any self-funded
insurance program or act as a self-insured employer.
Completed PEO Domicile & Contact Information Sheet (required)
Do you offer insurance benefit plan(s) to your leased employees? Yes
If yes, check the plan(s) you offer:
No
Life Medical Dental Vision
The Professional Employer Organization (PEO) Insurance Certification Form
must be included for each Benefit Plan offered.
Part #3 - Industrial Insurance Coverage as required by the Nevada Industrial Insurance and
Occupational Diseases Acts (Chapters 616A to 616D, inclusive, and Chapter 617 of the Nevada
Revised Statutes).
I hereby certify under penalty of perjury that Workers’ Compensation Insurance is maintained
for each Client listed in Section C of the application.
Each client must have Nevada Specific coverage or Nevada must be listed in 3A of the Declaration
page of the Master policy and must have correct client name on it.
I hereby certify under penalty of perjury that Workers’ Compensation Insurance is
maintained for internal staff.
Section B:
The application for PEO registration should be submitted in a complete and organized
manner. Incomplete submission will be returned without further review. The following
items must be included with the application:
Part #4 - Payment of contributions or payments in lieu of contributions to the Nevada
Employment Security Department as required by Chapter 612 of the Nevada Revised Statutes.
Include Nevada Employment Security Dept (DETR) Notice of Contribution or Wage
Report for each client listed in Section C of the application. (Confirmation from
DETR showing that an account number has been assigned may be submitted for new
companies.) The forms should be in the same order as the list of clients.
Part #5 – Financial Statement and Proof of Working Capital
NRS 616B.679(1)(h)
1.
(h) A financial statement of the applicant setting forth the financial condition of the Professional
Employer Organization. Except as otherwise provided in NRS 616B.679 subsection 5, the financial
statement must include, without limitation:
(1)
For an application for issuance of a certificate of registration, the most
recent audited financial statement that includes the applicant, which must have been
completed not more than 13 months before the date of application; or
(2)
For an application for renewal of a certificate of registration, an audited
financial statement that includes the applicant and which must have been completed
not more than 180 days after the end of the applicant’s fiscal year.
NRS 616B.679 subsection 5 and 6
5.
A financial statement submitted with an application pursuant to this section must be prepared in
accordance with generally accepted accounting principles, must be audited by an independent
certified public accountant licensed to practice in the jurisdiction in which the accountant is located
and must be without qualification as to the status of the Professional Employer Organization as a
going concern. Except as otherwise provided in subsection 6, a Professional Employer Organization
that has not had sufficient operating history to have an audited financial statement based upon at
least 12 months of operating history must present financial statements reviewed by a certified
public accountant covering its entire operating history. The financial statements must be prepared
not more than 13 months before the submission of an application and must:
(a)
Demonstrate, in the statement, positive working capital, as defined by generally accepted
accounting principles, for the period covered by the financial statements; or
(b)
Be accompanied by a bond, irrevocable letter of credit or securities with a minimum market
value equaling the maximum deficiency in working capital for the period covered by the financial
statements plus $100,000. The bond, irrevocable letter of credit or securities must be held by a
depository institution designated by the to secure payment by the applicant of all taxes, wages,
benefits or other entitlements payable by the applicant.
6.
An applicant required to submit a financial statement pursuant to this section may submit a
consolidated or combined audited financial statement that includes, but is not exclusive to, the
applicant.
Please mark the appropriate box for items included:
Audited Financial Statement Bond
Irrevocable Letter of Credit Securities
Include a copy of the appropriate page that demonstrates working capital in the
application.
Section B: Continued
Name of Business FEIN #
Primary Business Operation (Construction,
Sales, Etc.)
Business Address (P. O. Box NOT acceptable)
Business Telephone
Estimated Number of
Client’s Employees
Number of Leased
Employees
Estimated Monthly Payroll of Employees
Leased to Business
Entity Type:
Sole Proprietor
Corporation
Partnership
Name of Business FEIN #
Primary Business Operation (Construction,
Sales, Etc.)
Business Address (P. O. Box NOT acceptable)
Business Telephone
Estimated Number of
Client’s Employees
Number of Leased
Employees
Estimated Monthly Payroll of Employees
Leased to Business
Entity Type:
Sole Proprietor
Corporation
Partnership
Name of Business FEIN #
Primary Business Operation (Construction,
Sales, Etc.)
Business Address (P. O. Box NOT acceptable)
Business Telephone
Estimated Number of
Client’s Employees
Number of Leased
Employees
Estimated Monthly Payroll of Employees
Leased to Business
Entity Type:
Sole Proprietor
Corporation
Partnership
Name of Business FEIN #
Primary Business Operation (Construction,
Sales, Etc.)
Business Address (P. O. Box NOT acceptable)
Business Telephone
Estimated Number of
Client’s Employees
Number of Leased
Employees
Estimated Monthly Payroll of Employees
Leased to Business
Entity Type:
Sole Proprietor
Corporation
Partnership
Name of Business FEIN #
Primary Business Operation (Construction,
Sales, Etc.)
Business Address (P. O. Box NOT acceptable)
Business Telephone
Estimated Number of
Client’s Employees
Number of Leased
Employees
Estimated Monthly Payroll of Employees
Leased to Business
Entity Type:
Sole Proprietor
Corporation
Partnership
Section C:
List all client companies currently under contract with your firm. (Print additional sheets
if necessary.)
• I/we, the undersigned, swear under penalty of perjury that the information given in this form is true and
accurate and that each client has a valid worker's compensation policy in the State of Nevada as defined by
NRS 616B.692. I/we agree to submit to the Office of the Labor Commissioner, any changes in this information
within thirty (30) days, pursuant to NRS 616B.679 (3). Any falsification of this application or statements
therein will be cause for denial, revocation and/or Administrative Penalties being assessed.
This form must be signed by the sole proprietor, each partner, or each corporate officer of the Professional
Employer Organization. Each signature(s) must be notarized.
Signature of sole proprietor, partner, or corporate officer of
Professional Employer Organization
Full name of sole proprietor, partner, or corporate officer
of Professional Employer Organization (type or print)
Subscribed and sworn before me on this day of ,
20 , in County, State of
Notary Public Seal
Signature of sole proprietor, partner, or corporate officer of
Professional Employer Organization
Full name of sole proprietor, partner, or corporate officer
of Professional Employer Organization (type or print)
Subscribed and sworn before me on this day of ,
20 , in County, State of
Notary Public Seal
Signature of sole proprietor, partner, or corporate officer of
Professional Employer Organization
Full name of sole proprietor, partner, or corporate officer
of Professional Employer Organization (type or print)
Subscribed and sworn before me on this day of ,
20 , in County, State of
Notary Public Seal
Additional page(s) must be attached for additional signature(s) of all partners or additional
corporate officers.
Mail completed application packet to:
STATE OF NEVADA
OFFICE OF LABOR COMMISSIONER
1818 COLLEGE PARKWAY, SUITE 102
CARS0N CITY, NEVADA 89706
775-684-1890
Section D:
Declaration Page must be signed by each officer/director of the PEO
PEO CONTACT INFORMATION
Name of PEO:
Address of PEO:
Name of PEO Contact:
Title of PEO Contact:
Contact Phone:
Contact Fax:
Contact E-mail:
Professional Employer Organization (PEO)
Insurance Certification / Instruction Sheet
Line of Insurance: Complete a certification form for each line of insurance. Identify whether the
policy is medical, dental, vision or life insurance. If it is a voluntary product, such as cancer
protection, short-term disability, long-term disability, etc., it is not necessary to complete a
certification form.
Policy #: The Employer Group Policy number.
Form #: The form number of the policy. This number is typically found on the lower left hand
corner of the policy and will be compared to the Nevada Division of Insurance’s database to ensure
the Division has approved the form. An application cannot be approved without a valid form
number.
Licensed Nevada Insurance Company: The insurance company providing the policy must have a
Nevada Certificate of Authority to sell insurance products to Nevada residents.
Insurer’s NAIC ID#: The insurer’s National Association of Insurance Commissioner’s
identification number.
FEIN: The Federal employer’s identification number.
NV ID#: The identification number provided on the insurer’s Nevada Certificate of Authority.
Contact information for the “Licensed Salesperson/Producer” that marketed the above
referenced policy to the Professional Employer Organization (PEO): This section must be
completed by the person that actually marketed the insurance product to the PEO. This person is
responsible for the completion of the application and will be contacted by the Nevada Division of
Insurance to answer questions concerning the accuracy of the information provided.
Insurance Company Certification: An authorized representative of the insurance company and
the leasing company must confirm that the insurance product is fully insured. Fully-insured is a
plan where the employer contracts with another licensed organization to assume financial
responsibility for the enrollees’ claims and for all incurred administrative costs. The plan cannot
include stop-loss coverage or any other out-of-pocket expenses to the employer.
Professional Employer Organization’s Certification: The sole proprietor, partner or corporate
officer of the Professional Employer Organization must certify that the Company shall not offer its
employees any self-funded insurance program or be a member of an association of self-insured
public or private employers.
Professional Employer Organization (PEO) Insurance Certification
A Professional Employer Organization shall not act as a self-insured employer or be a member of an
association of self-insured public or private employers pursuant to chapters 616A to 616D, inclusive, or
Chapter 617 of NRS, or pursuant to Title 57 of NRS. Please complete this certification of compliance and
submit to the Office of the Labor Commissioner with the Professional Employer Organization (PEO)
Registration Application.
PEO Company Name
Line of Insurance:
Policy #:
Form#
Licensed Nevada Insurance Company:
Insurer’s NAIC#:
FEIN:
NV ID#:
Contact information for the “Licensed Salesperson/Producer” that marketed the above referenced
policy to the Professional Employer Organization (PEO):
Name:
Direct Telephone #:
Address:
Direct Fax #:
Direct E-mail Address:
Insurance Company’s Certification:
As an officer of the above-named licensed Nevada Insurance Company, I certify that the product provided
to the named Professional Employer Organization (PEO) is fully insured* and the policy form approved by
the Nevada Division of Insurance.
Printed Name in full Date
Signature Date
Professional Employer Organization’s Certification:
As an authorized representative of the above-named Professional Employer Organization (PEO), I certify
that the Company shall not offer its employees any self-funded insurance program or be a member of an
association of self-insured public or private employers.
Printed Name in full Date
Signature Date
*Fully-insured is a plan where the employer contracts with another licensed organization to assume financial
responsibility for the enrollees’ claims and for all incurred administrative costs. The plan cannot include stop-loss
coverage or any other out-of-pocket expenses to the employer.
An incomplete or inaccurate application will be returned to the Professional Employer Organization (PEO). All
certifications must be clearly signed and dated. A photocopy of an application will not be accepted.
OLC (rev 12/10/2021)
CHANGES TO THE PEO APPLICATION:
For PEO applications to be approved and/or renewed, you must certify, under penalty of perjury, that the
client(s) are covered in accordance with NRS Nevada Industrial Insurance and Occupational Diseases
Acts (Chapters 616A to 616D, inclusive, and Chapter 617 of the Nevada Revised Statutes). You must keep
records of the insurance policies and be able to provide them upon request.
The SMEAD folder is no longer required, but we do request you put the documents in a logical order so
we can easily enter them into our system for review. Please keep the order of documents as close to those
listed in Section B as possible.
The Office of the Labor Commissioner would like to announce that we have signed an agreement with
Employer Services Assurance Corporation (ESAC), a PEO Accreditation company. If you are registered
with ESAC, please review and update your accounts to meet the State of Nevada requirements. For more
information regarding ESAC and their services, please go to http://www.esac.org.
