1. Marshal Gibson
Business Development
(847) 217-6782 Direct
MGibson@EmployersLogic.com
“YOU HAVE THE EMPLOYESS . . . WE SOURCE THE SOLUTIONS” MARSHAL GIBSON (847) 217-6782
Cost Management Analysis
A. Organization Information
Legal Business Name
Street Address Fed ID#:
City State Zip
Contact Name(s)
Email(s)
Office Phone Cell Phone
# of Employees Payroll Frequency (weekly, bi‐weekly,etc.)
Total Weekly Payroll Amount: $
B. Current Human Resource Management Questionnaire (Please Circle the Correct
Answer)
1. Currently process your New Hire Reporting to your State Government? YES or NO
2. Do you process your payroll in‐house? YES or NO
3. Do you offer Direct Deposit to your employees? YES or NO
4. Do you currently offer an Orientation Package for New Hires? YES or NO
5. Do you have an up‐to‐date Employee Manual? YES or NO
6. Do you ever contract employees from a Temporary Agency? YES or NO
7. Do you administer COBRA in‐house? YES or NO
8. Do you have completed I‐9 forms on your employees? YES or NO
9. Do you have a Safety Program for your employees? YES or NO
10. Do you offer a 401(k) Plan to your employees? YES or NO
11. Do you currently complete your OSHA 200 Log? YES or NO
12. Do you currently offer your employees a Section 125 Cafeteria Plan? YES or NO
C. Circle any current Employee Issues or Concerns you would like to improve
for your Organization.
Medical or Dental Insurance, 401(k) Plan, Safety Program, Payroll Processing
Employee Manual, OSHA Compliance, Direct Deposit, Workers’ Compensation
Unemployment, Management, Legal, Compliance, Hiring Process, Employee Perks

2. “YOU HAVE THE EMPLOYESS . . . WE SOURCE THE SOLUTIONS” MARSHAL GIBSON (847) 217-6782
Marshal Gibson
Business Development
(847) 217-6782 Direct
MGibson@EmployersLogic.com
D. Workers’ Compensation Billing Report/Dec Page
Please attach your most recent Workers’ Compensation Declaration Page that includes the following:
Job Title or Code
Rate per Code
# of employees per Code
Annual Payroll
Identifying current classification(s), rates and modifiers is important for accuracy. (Note: This
document is also referred to as: Billing Statement, Declarations Page and/or Schedule of Operations)
 Workers’ Compensation Loss Runs/Claims History (3 years)
E. State Unemployment Information
Please attach your most recent State Unemployment Statement.
F. Benefit Information
Please attach a copy of your most recent Health, Dental & Life Insurance Statements.
Master Payroll Report
For each employee: Name, Age, Gender, Home Zip Code, Job Function, Work State, Monthly Salary or
Hourly Rate, Full or Part Time Status, Current Medical Election.
Benefits (Medical/Dental/Vision, etc.) Billing Statement(s)
 Copy of most recent monthly invoice.
 If the medical is up for renewal within the next 60 days, please provide a copy of your
renewal quote.
 Medical Plan summary for the current year.
 Renewal date for the current plan.
Note: Some of these items are not necessary, if you indicated, for example, that you currently
don’t provide Medical Benefits. The main items that will help us determine the reduction in
your payroll costs are Workers Comp Class(s) and your SUTA (State unemployment) costs.