COVER-PRO
SM
APPLICATION
EMPLOYMENT AGENCY / PEO / TEMPORARY EMPLOYMENT / RECRUITER SUPPLEMENT
1. Full name of the Applicant Firm:
2. Please indicate the percentage of the Applicant Firm’s gross an
nual reve
nue
for the pa
st twelve (1
2) m
onths
from eac
h activity:
Traditional employment agency: % Contingency/Executive search: %
Temporary help: % Career counseling: %
Outplacement: % Retained search: %
Contract employee: % Professional Employee Organization: %
Other: % Other: %
TOTAL MUS
T EQUAL 100 %
3. Is the Applicant involved in any hiring or firing d
ecisions? Yes No
4. Please indicate the percentage of types of professi
onals placed in the past twelve (12
) months:
Advertising: % Insurance: %
Architect & Engineer: % Land Surveyor: %
Attorneys/Accountants/CPA: % Mortgage Broker: %
Bookkeeper: % Physician/Surgeon: %
Computer Consultant: % Real Estate: %
Consultant: % Other: %
Dentist: % Other: %
Financial Advisor: % Other: %
Interior Designer: % TOTAL MUS
T EQUAL 100 %
5. For profession
als that are placed on a temporary or permanent basis, does the Applicant require that those
profe
ssionals maintain professional liability insuranc
e? Yes No
6. Are any tests administered to job applicants? Yes No
7. Please describe the specific steps and procedures in which the Applicant takes to investigate and verify the
backg
rounds, qualifications and credentials of job candidates.
8. What steps does the Applicant take to protect a job candidate’s confidential information from being released to
an una
uthorized party?
9. Is workers’
compensation insurance currently in forc
e? Yes No
10. Are all temporary employees covered unde
r this insurance? Yes
No
PI-PLSP-EASUPP 08/10 Page 1 of 2
