EMPLOYEE LEASING COMPANY
Registration INFORMATION

The information below must be included with the registration application for Employee Leasing Companies in the State of Maine pursuant to 32 M.R.S. Chapter 125.

	  Employee Leasing Company Registration Application (Online) 
	  Payment of $500(new) / $100(renewal) registration fee 
   (check payable to: Treasurer, State of Maine)
	  List of all workers’ compensation insurance polices issued to the registrant.
	  Name, address, and Maine license # of the workers’ compensation insurer.
	  Copy of the current workers’ compensation certificate of liability
	  Name, address, and Maine license # of the producer handling the sale of w/c coverage.
	  Name, address, and Maine license # of the agency handling the sale of w/c coverage.

If applicable:
	  Name, address, and Maine license # of the health insurer.
	  Name, address, and Maine license # of the producer handling the sale of health coverage.
	  Name, address, and Maine license # of the agency handling the sale of health coverage.