Contract Termination by ayj58676

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									                                                                                                      PROFESSIONAL EMPLOYER ORGANIZATION
                                                                                                          CLIENT RELATIONSHIP NOTIFICATION




INSTRUCTIONS:
Use this form to notify BWC of new client, change of relationship with current client, or termination of client.
Mail form to BWC, Risk Technical Services - L-22, 30 W. Spring Street, Columbus, OH 43215-2256 or fax to (614) 728-3205.


                                           PROFESSIONAL EMPLOYER ORGANIZATION INFORMATION
Company Name                                                                                        Policy number


Contact person name                                                                                 Telephone number

                                                                                                    1-800-456-2885



                                                         CLIENT COMPANY INFORMATION
CHECK ONLY ONE                                                                                      Effective date of contract, termination or change

New client information                Change of policy number reporting payroll
Contract termination information      Change to portion of client's employees assumed by PEO
                                                                                                    Date
First day of payroll accrual to which this agreement/change applies



Client company name                                                                                 Client policy number


DBA                                                                                                 Federal I.D. number

Mailing address (P.O. Box if applicable)


City                                                         State                                  9-digit ZIP Code




Will the professional employer organization assume

                                      all of the employees? a portion of the employees?
                                                            List classifications of client reportable by PEO




Policy number under which
employees will be reported 1084333

                                                                              Title                                        Date
Print client name

Client signature

Print PEO name

PEO signature

           (Signatures are required by both parties indicating the above information is true to the best of their knowledge.)
BWC-8003 (Rev. 2/28/2000) PC
UA-3

								
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