Fill out our FREE Unemployment Account Evaluation:

(Please fill out the form below in its entirety, including uploading two copies of your most recent State Unemployment Tax Rate Notices)

For any questions, please contact: kent@unemploymentservices.com, Phone: 248-926-8900, Fax: 248-926-8902

UNEMPLOYMENT ACCOUNT EVALUATION FORM

Contact Name

First Name

Last Name

Job Title

Company Name

Industry of Business

Number of Locations

City

State

Zip

Phone

Country

(###)

###

####

Fax

Number of Part Time Employees

Number of Full Time Employees

Number of W-2s last year

Current Funding Method

Paying State Unemployment Tax

Reimbursing

If managed externally, please identify your current administrator/program:

Have you experienced any lay-offs or staff reductions in the past 24 months? If so, how many?

Do you expect any layoffs or to eliminate any positions during the next 12 months?

How many Quit and Discharge claims do you receive each year?

Last Year's Unemployment Tax Rate:

Current Year's Unemployment Tax Rate:

Tax paying employers: please provide copies of your two most recent State Unemployment Tax Rate Notices. The information provided on this application form is true, accurate, and complete to the best of my knowledge. I acknowledge that any misrepresentation will result in the immediate cancellation of any service or coverage pursuant to the terms of this product for which this application is submitted. This form also serves as a temporary authorization allowing Unemployment Services, Inc. (an Amynta Company) to review employer’s unemployment account with the State tax department. Thank You.

Get Started.

For a Free Evaluation please send a copy of your most recent tax rate determination to our office via email kent@unemploymentservices.com or fax to 248-926-8902.

Name

First Name

Last Name

Company Name

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