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Request for Leasing Employees

Please read carefully:

  • All questions must be answered.
  • All fields are required to process your request.
  • Incomplete applications may delay processing.
  • If a question does not apply, write “N/A.”
  • Confidentiality: Agri-Placement Services, Inc. (APS) treats all information as strictly confidential and uses it only to provide services.
  • If you need a printable version, download this PDF, complete it, and send it to contact@agriplacement.com using Request for Leasing Employees as the subject line.
1

Employer & Business Information

2

Placement Details

3

Workers Compensation

Employer & Business Information

Please complete this section to provide details about your business structure and operations.

1

Employer & Business Information

Employer Information

Company Name *
EIN (Employer Identification Number) *
Employer Physical Address *
Employer Mailing Address (If same as physical address, enter “N/A”) *
Contact Person(s) *
Phone Number(s) *
Cell Number(s) *
Fax Number(s) (If not applicable, enter “N/A”) *
Email(s) *

Business Information

Banking Institution Name *
Bank Contact Person *
Bank Phone number *
Authorized Signers' Names *
I understand that automatic or electronic payment of monthly fees will be required *
1

Employer & Business Information

2

Placement Details

3

Workers Compensation

Placement details

Please complete this section to describe the type of work, tools, equipment, and practices used in your operations.

2

Placement Details

Employer Information

# of Employees Needed *
Date of Need *
Average Hour Work Week (per employee) *
Hourly Wage *
Job Duties/Description (brief) *
Lifting Limits (as part of job duties) *
Operational Type *
1

Employer & Business Information

2

Placement Details

3

Workers Compensation

Workers Compensation

Complete this section to include all required information and documents related 
to your workers’ compensation coverage.

3

Workers Compensation

Three Years of Loss Runs

Please provide the workers’ compensation loss runs for the past three years.

Maximum 2 MB. The file must be in PDF format.

Workers’ Compensation Declaration Page

Including current classification codes listed on the existing or most recent policy.

Maximum 2 MB. The file must be in PDF format.

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Need a printable version to fill out by hand?

Download the PDF.

Leasing Employee Request PDF