North Carolina Employment Agency

Form PEO-01: Professional Employer Organization License Application

Mail or email to SpecialEntitiesSubmissions@ncdoi.gov. Forms requiring notarization must be sent in the mail.

$1,000

• A list by jurisdiction of each name under which the applicant has operated in the preceding 5 years, including any alternative names, names of predecessors and, if known, successor business entities.
• Form PEO-02: Biographical Affidavit for each controlling person
• List of officers, directors and controlling persons
• Names of all persons or entities who directly or indirectly own, control, hold with the power to vote, or hold proxies representing 10% or more of the voting securities of the applicant.
• A list of all offices located in North Carolina
• Description of the applicant's operations in the state of North Carolina
• List of all client companies in North Carolina
• Surety bond, letter of credit, or cash deposit
• Form PEO-04: Power Of Attorney if the applicant is a nonresident
• Form PEO-05: Obligations Attestation
• A copy of the applicant's most current audited GAAP financial statement, prepared as of a date not more than 90 days before the date of application
• A complete set of fingerprints for each officer, director, and controlling person
• 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
• 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
• For each client company listed in section 3, attach evidence of workers' compensation coverage for all assigned employees in North Carolina
• Form PEO-17: Workers' Comp Attest

Annual Filing Requirements

$1,000

Annually within 120 days after the close of the PEO's fiscal year.

• Audited GAAP financial statement
• Form PEO-05: Obligations Attestation
• Form PEO-06: CEO and CFO Fin Stmt Attest
• Any changes to information reported on the initial registration application
• Current Surety Bond, Letter of Credit, or Current Statement of Securities
• Current client list of all North Carolina clients serviced by the PEO

Form PEO-05: Obligations Attestation

$0

Within 45 days after the end of each fiscal year quarter.

Licensees must submit financial reports including GAAP financial statements and the obligation attestation form every quarter.

Form PEO-11: Notification of Initiation of Client Company or Form PEO-12: Notification of Termination of Client Company

$0

Within 30 days of initiation or termination of a client company relationship.

Licensees must file a notification when initiating or terminating a client company relationship.

Form PEO-10: Notification of Change

$50 if there is a change to the name of the licensee, otherwise there is no fee.

Within 30 days of a change.

Licensees must report a change in name of licensee, change in location of licensee’s primary business office, addition of business office in NC, deletion of business office in NC, change in location of a business office in NC, addition of controlling person, deletion of controlling person, and any other material change in business structure, bankruptcy filing, any regulatory or judicial action against licensee.

Form PEO-13: Notification of Change in WC Ins or HB Plan

$0

No later than 10 days after discontinuance.

PEOs must notify the client company and the Commissioner about a discontinuance and replacement, if any, of any health plan or workers' compensation insurance coverage.

Form PEO-01: Professional Employer Organization License Application

Mail or email to SpecialEntitiesSubmissions@ncdoi.gov. Forms requiring notarization must be sent in the mail.

$1,000

• A list by jurisdiction of each name under which the applicant has operated in the preceding 5 years, including any alternative names, names of predecessors and, if known, successor business entities.
• Form PEO-02: Biographical Affidavit for each controlling person
• List of officers, directors and controlling persons
• Names of all persons or entities who directly or indirectly own, control, hold with the power to vote, or hold proxies representing 10% or more of the voting securities of the applicant.
• A list of all offices located in North Carolina
• Description of the applicant's operations in the state of North Carolina
• List of all client companies in North Carolina
• Surety bond, letter of credit, or cash deposit
• Form PEO-04: Power Of Attorney if the applicant is a nonresident
• Form PEO-05: Obligations Attestation
• A copy of the applicant's most current audited GAAP financial statement, prepared as of a date not more than 90 days before the date of application
• A complete set of fingerprints for each officer, director, and controlling person
• 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
• 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
• For each client company listed in section 3, attach evidence of workers' compensation coverage for all assigned employees in North Carolina
• Form PEO-17: Workers' Comp Attest

Annual Filing Requirements

$1,000

Annually within 120 days after the close of the PEO's fiscal year.

• Audited GAAP financial statement
• Form PEO-05: Obligations Attestation
• Form PEO-06: CEO and CFO Fin Stmt Attest
• Any changes to information reported on the initial registration application
• Current Surety Bond, Letter of Credit, or Current Statement of Securities
• Current client list of all North Carolina clients serviced by the PEO

Form PEO-05: Obligations Attestation

$0

Within 45 days after the end of each fiscal year quarter.

Licensees must submit financial reports including GAAP financial statements and the obligation attestation form every quarter.

Form PEO-13: Notification of Change in WC Ins or HB Plan

$0

No later than 10 days after discontinuance.

PEOs must notify the client company and the Commissioner about a discontinuance and replacement, if any, of any health plan or workers' compensation insurance coverage.

Form PEO-10: Notification of Change

$50 if there is a change to the name of the licensee, otherwise there is no fee.

Within 30 days of a change.

Licensees must report a change in name of licensee, change in location of licensee’s primary business office, addition of business office in NC, deletion of business office in NC, change in location of a business office in NC, addition of controlling person, deletion of controlling person, and any other material change in business structure, bankruptcy filing, any regulatory or judicial action against licensee.

Form PEO-11: Notification of Initiation of Client Company or Form PEO-12: Notification of Termination of Client Company

$0

Within 30 days of initiation or termination of a client company relationship.

Licensees must file a notification when initiating or terminating a client company relationship.

http://www.nclabor.com/wh/forms.htm

$500

http://www.nclabor.com/wh/forms.htm

$500

Annually