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Request for Leasing Employees

Please read carefully:

  • For employers only. Looking for job applications? Click here.
  • 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

Industry type *
Milk Cooperative Company *
Contact Person *
Contact Phone number *
Producer ID # *
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.

We Respect Your Privacy

We securely store your data, comply with all applicable privacy laws and regulations, and never sell or share your data. Read our full Privacy Policy for more information.

Need a printable version to fill out by hand?

Download the PDF.

Leasing Employee Request PDF

Our Partners:

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APS partners with businesses in over 20 U.S. states to provide reliable, hard-working employees—serving as an extension of their HR teams and simplifying the hiring process so they can focus on growth.

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Contact Us

  • 510 Clinton Square, PMB 5010
Rochester, NY 14604
  • 315-986-4738 Office

    802-329-2217 Fax
  • contact@agriplacement.com

About Us

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