Free PDF template

PEO Workers' Compensation Verification Checklist

A fillable checklist for identifying the policy structure, named insureds, covered workers, state treatment, certificate process, claims reporting, audit data, and exit transition in a PEO arrangement.

Free to use · Educational workflow tool · U.S. small-business focus

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Who this is built for

Small employers using or considering a professional employer organization.

How to use it

  1. Ask the PEO and insurance contact how workers' compensation is issued in each work state; do not assume every PEO uses the same structure.
  2. Separate leased/worksite workers from any direct employees and confirm whether both groups are addressed.
  3. Before leaving a PEO, obtain loss/payroll data and confirm how the replacement workers' compensation policy will preserve required state coverage.

What the template captures

PEO legal nameClient legal nameWork statesPolicy issuance structureCarrier/policy numberNamed insured wordingLeased workers coveredDirect workers coveredEmployers liabilityOther statesCOI processClaims reportingAudit/payroll dataExperience dataContract start/endExit transition owner

What this template cannot prove

A worksheet or email template cannot create insurance coverage, establish legal worker status, modify an insurance policy, or guarantee that a contract requirement has been satisfied. When a field depends on coverage, confirm the policy or endorsement. When it depends on state law, use the responsible state authority.

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