By submitting this form, you will allow us to perform a savings analysis on your option as a 501(c)(3) to become a nonprofit reimbursing employer. Your organization should have a minimum of 15 full-time employees. 

 
 
 
   
   
First Name*  
 
Last Name*  
 
Job Title*  
 
Organization Name*  
 
Email*  
 
Work Phone*  
 
   
   
 
   
   
State*  
 
How does your organization currently pay for unemployment?*  
 
Annual Payroll *  
 

This figure should be the sum of your last four quarters of payroll.

 
 
 
  

If you have any questions about this form or the entire process, please feel free to call (800) 631-2967 or email us.