PEO - Employee Leasing Forms

Industry InformationProfessional Employer Organizations (PEO)

Professional Employer Organization (PEO) – Employee Leasing Forms

Use one of the following forms to manually report audited exposure, premium, and loss information when:

A client leaves a PEO arrangement covered under a master policy and the PEO’s data provider reports to NCCI the client’s data developed during the employee leasing arrangement.

A client is covered in Nevada under a PEO master policy, and the PEO’s data provider reports the client’s data concurrent with the reporting of the Unit Statistical data for the PEO’s policy.

• National Employee Leasing Form NC2745 (PDF)
• Florida Employee Leasing Form FL1372 (PDF) 
• Nevada Employee Leasing Form NV361 (PDF)
• Virginia Employee Leasing Form VA1271 (PDF)   

Refer to Part 9—Hard Copy Reporting of the Experience Rating (ER) Split Data Reporting Guide for instructions to properly complete these forms.

Request for Separate Experience Data

When changes in ownership interest affect the use of an entity’s experience in future experience ratings, NCCI may request individual exposure and claim information for an individual employer. The Request for Separate Experience Data form may be attached to an ownership ruling letter issued by NCCI.

The Request for Separate Experience Data will only be sent by NCCI if additional experience information is needed. The following is a sample of the ownership ruling letter and the Request for Separate Experience Data.