Financial Oversight & Special Entities Division

If the Applicant is organized in the State of North Carolina, provide the name and address of the Applicant’s registered agent:

Provide a list by jurisdiction of each name under which the Applicant has operated in the preceding five (5) years, including any alternative names, names of predecessors and, if known, successor business entities. The list shall include the parent company name, if any, and any trade name, trademark, or service mark of the Applicant:

Is the Applicant a part of a group of entities under common control that is applying for a group license in accordance with N.C. Gen. Stat. § 58-89A-35?

• If “Yes,” complete the questions below and submit an executed Form PEO-03 (Unconditional Cross Guaranty Agreement Between Professional Employer Organization Group Members Made for the Direct Benefit of the Commissioner of Insurance In His Official Capacity) and an executed Form PEO-16 (Corporate Resolution of Guarantor). Only one Form PEO-03 is required per group.

• If “No,” skip the questions below and move to subsection D.

• If “No,” and the PEO Group is submitting consolidated financial statements of the ultimate controlling person, submit an executed Form PEO-14 (Unconditional Guaranty Agreement Between Professional Employer Organization Group Members and Guarantor Made for the Direct Benefit of the Commissioner of Insurance In His Official Capacity) and an executed Form PEO-16 (Corporate Resolution of Guarantor). Only one Form PEO-14 is required per group.

Please list the names of each entity applying for group licensure as a member of the above referenced group:

Each entity named above must submit a separate application.

Please complete the questions below relating to the Applicant. If any question is answered “Yes,” attach a separate addendum detailing the circumstances (including any applicable details such as state, license number, dates, etc.).

IMPORTANT: Fill out each section completely, even if the same individual is listed in several sections of this form.

Please ensure a Biographical Affidavit (Form PEO-02) is submitted for each controlling person (not including entities that are controlling persons), officer, and director listed below.

Controlling Persons Based on Ownership

Please list the names of all person(s) or entities who directly or indirectly own, control, hold with the power to vote, or hold proxies representing ten percent (10%) or more of the voting securities of the Applicant:

Officers, Directors, and Controlling Persons Based on Position

Please list the names and titles/positions of all officers, directors, and any person who is a controlling person based on their position with the Applicant:

Other Controlling Persons

Please list any other person who has, by contract (other than a commercial contract for goods or non-management services) or otherwise, the authority or power to control the management and policies of the Applicant or to obligate the Applicant with respect to a material contractual matter such as entering into a professional employer service contract with a client company. IF NONE, SO STATE.

Provide a list of all offices located in North Carolina:

Describe the Applicant’s operations within the State of North Carolina. Include in this description whether the Applicant is currently offering or engaging in professional employer services in North Carolina and the total number of assigned employees in North Carolina as of the date of Application.

Provide a list of all client companies in North Carolina. For client companies having multiple locations with the same FEIN, please list only the headquarters location. This information may be provided by a separate report if all the requested information is included in the separate report:

* Business Classification Code

In accordance with N.C. Gen. Stat. § 58-89A-50, an Applicant for licensure shall file with the Commissioner a surety bond, letter of credit, cash, or securities in the amount of one hundred thousand dollars ($100,000) for the benefit of the Commissioner. An Applicant whose current assets do not exceed current liabilities pursuant to N.C. Gen. Stat. § 58-89A-60(b) shall file an additional surety bond or other items set forth below equal to, or in excess of, current liabilities less current assets.

Please provide one of the following and submit it with the Application:

1. A surety bond in favor of the State of North Carolina, in a form acceptable to the Commissioner (Form PEO-08), issued by an insurer authorized by the Commissioner to write surety business in the State of North Carolina.
2. An irrevocable letter of credit in a form acceptable to the Commissioner (Form PEO-09), issued by a financial institution, the deposits of which are insured by the Federal Deposit Insurance Corporation.
3. Cash or securities, as specified in N.C. Gen. Stat. § 58-5-20. If depositing cash or securities, Form PEO-07 must be completed and forwarded to the Department. (Contact the Financial Oversight and Special Entities Division at (919) 807-6612 for specific instructions.)

Note: If applying for a Group Professional Employer Organization License, only one surety bond, letter of credit, or cash/security deposit is required per group.

All forms can be obtained from the North Carolina Department of Insurance website:
https://www.ncdoi.gov/licensees/professional-employer-organizations-peos/professional-employer-organizations-forms

Exhibits or attachments requested below are required and must be provided before the application is considered complete. If a requested item is not applicable or available, include an explanation stating why. Failure to comply may result in your application being delayed or denied.

1. Submit a Biographical Affidavit (Form PEO-02) for each controlling person (not including entities that are controlling persons), officer, and director listed in Section 2 of this application.
2. If the Applicant is a nonresident, submit an executed Form PEO-04. Please be sure to affix the Applicant’s corporate seal to the PEO-04 document. If the Applicant does not have a corporate seal, write “no seal” on the form.
3. Attach an executed Applicant/Licensee Obligations Attestation (Form PEO-05).
4. In accordance with N.C. Gen. Stat. § 58-89A-60(b), submit a copy of the Applicant’s most current audited financial statement, prepared as of a date not more than 120 days before the date of application, that demonstrates the Applicant has a tangible net worth of not less than $50,000 and positive working capital. If the statements are more than 120 days old, provide an unaudited interim financial statement from the most recent quarter. Attach an executed copy of Form PEO-06 to the audited financial statement.
5. The Commissioner may accept the audited financial statement of an Applicant’s parent company if the audited financial statement includes either a combining or consolidating balance sheet, income statement, statement of changes in equity, and statement of cash flows as supplemental information to the audited financial statement, the contents of which will allow the Commissioner to determine the financial condition and responsibility of the parent company in lieu of the Applicant, if all of the following requirements are satisfied:
   • The parent executes a guaranty agreement, in a form prescribed by the Commissioner, for the guaranty of all obligations related to the Applicant’s current and future client companies, including its obligations for payroll, payroll-related taxes, workers’ compensation insurance, and employee benefits.
   • The Applicant files with the Commissioner documentation acceptable to the Commissioner evidencing the parent’s control.
   • The Applicant submits an audited financial statement that meets the requirements of N.C. Gen. Stat. § 58-89A-60(b1) that allows the Commissioner to determine the financial condition and financial responsibility of the parent and the Applicant.
6. A PEO that has not had sufficient operating history to have audited financial statements based upon at least 12 months of operating history may meet the financial requirements of N.C. Gen. Stat. § 58-89A-60(b1) by filing with the Commissioner financial statements that have been reviewed by an independent certified public accountant and that have been prepared as of a date not more than 90 days before this application.
7. Submit a complete set of fingerprints of each officer, director, and controlling person (non-entity) listed in Section 2 of this application. Also submit a properly executed Form 01-132-15 (Authority for Release of Information) and the required processing fees. The exact form and method for submitting this information is detailed in Form PEO-15.
8. If the Applicant is organized under the laws of another state as a corporation, limited partnership, limited liability partnership, or limited liability company, attach a current copy of the relevant certificate or a copy of the current annual report issued by the North Carolina Secretary of State evidencing the Applicant’s authority to conduct business in North Carolina.
9. If the Applicant is organized under North Carolina law as a corporation, limited partnership, limited liability partnership, or limited liability company, attach a current copy of the relevant certificate or a copy of the current annual report issued by the North Carolina Secretary of State.
10. For each client company listed in Section 3, attach evidence of workers’ compensation coverage for all assigned employees in this State, including those leased from or co-employed with another person.
11. Complete and attach Form PEO-17 certifying to the Commissioner that the Applicant has provided its workers’ compensation carrier with proper and necessary documentation to allow the carrier to determine and charge a premium that is commensurate with exposure and anticipated claim experience for all employees covered under policies issued by the carrier in the name of the Applicant.
12. With respect to any insurance or benefit plan provided by the Applicant for the benefit of its assigned employees, please provide benefit summaries from each carrier and disclose all of the following:
    • The type of coverage.
    • The identity of each insurer for each type of coverage.
    • The amount of benefits provided for each type of coverage and to whom or on whose behalf benefits are to be paid.
    • The policy limits on each insurance policy.
    • Whether the coverage is fully insured, partially insured, or fully self-funded.
13. If the Applicant offers to its assigned employees any health benefit plan that is not fully insured by an authorized insurer, please provide evidence that:
    • The plan utilizes a licensed or registered third-party administrator.
    • All plan assets, including participant contributions, are held in a trust account.
    • The plan provides sound reserves as determined by using generally accepted actuarial standards.

The Applicant must submit a non-refundable $1,000 application fee. All checks are to be made payable to the North Carolina Department of Insurance.

For submissions sent via the United States Postal Service:

North Carolina Department of Insurance
1203 Mail Service Center
Raleigh, NC 27699-1203
Attention: Financial Analysis & Receivership Division

For submissions sent via UPS or FedEx:

North Carolina Department of Insurance
3200 Beechleaf Court, 7th Floor
Raleigh, NC 27604
Attention: Financial Analysis & Receivership Division

Note: If applying for a Group Professional Employer Organization License, only one $1,000 non-refundable application fee is required per group.