HomeMy WebLinkAboutscan'0
Client File Requirements Checklist for PEO/CBP MATRD
4;neSOurce
A Vensure Employer Services Company
Information and Checklist
Client Name:Valrose Investment Group LLC Date: 03/02/2022
Consultant/Broker: Thomas Deming
EOriginal signed and dated Client Service Agreement with all necessary exhibits
El Signed Exhibit "A"
F] 3 -Years loss runs or signed "Loss History Affidavit Form" if no losses. Plus Request (PEO)
F-1PEO-CBP closed deals require Certificate of Work Comp. Insurance naming "MatrixOneSource" as the cert
holder. Loss runs are not required for GBP deals.
Completed "Client Set -Up Sheet"
Signed "Issuing a Certificate of Insurance" form
ZCompleted Employee Enrollment Applications for All Current Employees
`If applicable- EE Child Support Deduction Agreement
PEO-CBP closed deals require work comp. disclosure signed by each employee
ESigned "Retention of 1-9 Forms"
F Enrollment Forms Orientation: BC (initials):
FReporting Accident Procedure Form: BC (Initials):
Client (Initials): JG
Client (Initials): JG
Certificate of Insurance for General Liability (Work Comp if CBP) & (and Auto, if applicable) listing the certificate
E! holder as: "MatrixOneSource"
G.L. Certificate must be received by Matrix within 72 business hours.
Client Profile Submission (Page 2) signed by the owner / principal
- -- ------------- - - ----
Website Forms BC (initials): Client (Initials):
Workers' Comp. request form enclosed (if applicable)
DOL Overtime Form
N Deductible Program
Collateral Required
Notes/Remarks:
Valrose Enterprises Inc., DBA Awnings By Valrose reassigning employees and payroll to Valrose Investment group LLC
Please Use EXISTING DIRECT DEPOSITS ON FILE
Business Consultant Signature:
Date: 03/02/2022
MOSFORM-FULLPEOENROLLMENTPACK 1 @2020 MatrixOneSource
'0
RD
Client Service Agreement (FOGA) & AT
�neSOurce
A Vensure Employer Services Company
CLIENT SERVICE AGREEMENT FOR Valrose Investment Group LLC
This Client Service Agreement is entered into on 03102 2022 , by and between the client
identified on the signature page to this Client Service Agreement (hereinafter, the "Client"), whose address is set forth
on the signature page to this Agreement, and MatrixOneSource (hereinafter, including any successor and/or assignee
thereof, ("Matrix")', whose address is 9016 Philips Hwy., Jacksonville, Florida 32256.
1. TERM.
Unless otherwise terminated in accordance with the provisions of this Agreement, this Agreement shall remain in full force
and effect until either party gives at least forty-five (45) days prior written notice to the other of its termination..
11. SERVICES.
A. Matrix agrees to lease employees to Client to perform the job functions identified by the workers' compensation
code classifications agreed to by the parties ("Leased Employees"). Matrix shall not be considered to be a joint
employer of Leased Employees, but may be considered to be a co -employer solely for the limited purpose of
complying with Matrix's obligations under this Agreement. Client warrants that the list of workers' compensation
classification codes provided by Client to Matrix is accurate and complete and that the Leased Employees performing
these job functions do so at the location specified in this Agreement as Client's address. Client understands and
agrees that written approval from Matrix's workers' compensation carrier must be obtained prior to Client assigning
a Leased Employee work that is in a workers' compensation classification code not agreed to in writing by Matrix.
Matrix shall give written notice of the relationship between Matrix and Client to each Leased Employee Matrix assigns
to perform services at Client's worksite.
B. Client agrees and understands that no individual (i) shall become a Leased Employee, (ii) shall become co -employed
by Matrix, (iii) shall be covered by Matrix's workers' compensation insurance policy, or (iv) shall be entitled to any other
benefit of co-empioyment with Matrix or be issued a payroll check by Matrix, unless the individual has completed
Matrix's employment application, a W-4 withholding form, and any other documents required by Matrix, all of which must
be delivered to Matrix before the individual commences co -employment with Matrix. Matrix shall not be considered to
be a co -employer of any person until the person fully and accurately completes the foregoing forms and Client is notified
that the individual has been retained by Matrix as a Leased Employee. In addition, Matrix shall not be considered to be a
co -employer of any person (including a Leased Employee) for whom payroll information is not supplied by Client during
any payroll period (except as may be required by law). Client assumes full responsibility for workers' compensation
claims of any individual hired by or working for Client, whether as an employee, independent contractor, or in any other
status, if Client and the individual have not fully complied with all of the requirements of this Agreement for the individual
to become a Leased Employee of Matrix.
C. Client shall retain such sufficient direction and control over Leased Employees as is necessary to conduct Client's
business and without which Client would be unable to conduct its business, discharge any fiduciary responsibility that
it may have, fulfill its obligations to Leased Employees, or comply with any applicable licensure, regulatory, or statutory
requirement of Client. Client shall be considered the sole employer of Leased Employees for licensing purposes.
Notwithstanding the foregoing, and only to the extent required by law, Matrix reserves a right of direction and control
over Leased Employees assigned to Client's location, which may or may not be exercised, for the limited purpose of
enabling Matrix to fulfill its obligations under this Agreement. Notwithstanding the reservation of the foregoing right by
Matrix. Client acknowledges that (i) Matrix is required by law to reserve such right but that Matrix is not obligated to
exercise such right, (ii) Matrix assumes no responsibilities or liability merely as a result of its reservation of such right,
and (ii) Matrix shall have no liability to Client, any Leased Employee, or any third party in the event Matrix fails, elects, or
refuses to take any action to exercise such right.
t MatrixOneSource is the business name (known as a "d/b/a" or fictitious name) used by several affiliated entities. The initial Matrix entity that is a party
to this Agreement is the entity whose name appears on the signature page of this Agreement. if no such name appears, then the initial entity snail aet
he entity whose name appears on the Leased Employees' compensation paystubs or records.
MOSFORM-FULLPEOENROLLMENTPACK 2 @2020 MatriXOneSoume
"o
MATR
Client Service Agreement {FOGA
&,neSource
A Vensure Employer Services Company
D. To the extent required by law, Matrix retains the authority to hire, terminate, discipline, and reassign Leased
Employees, however, Client has the right to accept or cancel the assignment of any Leased Employee. The retention
of authority hereunder does not require the actual exercise of such authority by Matrix at any worksite at which or
from which a Leased Employee works. Client is hereby allocated the authority to hire, terminate, and discipline Leased
Employees to the fullest extent permitted by law.
E. To the extent required by law, Matrix assumes responsibility for the payment of wages to Leased Employees without
regard to payments by Client to Matrix. Matrix further assumes full responsibility for the payment of payroll taxes and
the withholding and collection of taxes from payroll for Leased Employees on payroll processed by Matrix for Leased
Employees. Matrix retains the right to employment tax deductions and credits allowed under federal law with respect to
Leased Employees. Matrix does not assume any responsibility for, and makes no assurances, warranties, or guarantees
as to the ability or competence of any Leased Employee to perform any work.
F. Matrix shall have no responsibilities with regard to Leased Employees' performance of their day-to-day job duties.
Furthermore, Matrix shall have no control over the job site at which, or from which, Leased Employees perform their
services. Client acknowledges and agrees that the control over the day-to-day job duties of Leased Employees and over
the job site at which, or from which, Leased Employees perform their services, is solely and exclusively, Client's. Client
expressly absolves Matrix of control over the day-to-day job duties of the Leased Employees and over the job site at
which, or from which, Leased Employees perform their services.
G. This Agreement in no way alters any obligations or responsibilities of Client to perform work history checks, reference
checks, or background checks on Leased Employees, and Client understands that Matrix shall have no obligation or
responsibility to perform such checks.
111. WORKERS' COMPENSATION INSURANCE.
A. Matrix shall secure workers' compensation insurance coverage in such amounts as is required by applicable
law covering Leased Employees and shall be responsible for the management of workers' compensation claims,
claims filings, and related procedures for Leased Employees when such claims arise out of services they perform
as Leased Employees in accordance with this Agreement. Client assumes full responsibility for providing coverage
and managing workers' compensation claims pertaining in any way to any individual for whom payroll information
is not supplied during any payroll period (except as may be required by law), or who is paid in whole or in part
by Client in any way other than through Matrix's normal payroll cycle. Client also assumes full responsibility for
workers' compensation benefits due or incurred by Matrix or Matrix's workers' compensation insurance carrier as a
result of workers' compensation claims of any Leased Employees arising out of injuries incurred while such Leased
Employees were performing job functions that are beyond the scope of the workers' compensation classification
codes set forth in an Exhibit to this Agreement. In all circumstances, Client shall retain and assumes full
responsibility for workers' compensation claims of any persons other than Leased Employees working or located at
any of Client's work sites.
B. Client may not permit Leased Employees to perform any tasks not contemplated by the workers' compensation code
to which they are classified, and Client further agrees not to conduct any business operations not contemplated by the
codes set forth on any Exhibit to this Agreement without notifying Matrix of such change in writing and without obtaining
Matrix's prior written approval to conduct such activities. Matrix reserves the right to determine and change the workers'
compensation classification codes of Leased Employees.
C. Matrix and its assigns have the right, which may or may not be exercised, to conduct an annual onsite physical
examination of Client for the purpose of determining the proper workers' compensation classifications of Leased
Employees and of determining the payroll amounts paid to Leased Employees. Such examination shall allow for the
audits of Clicnt for the purposes sot forth hereinabove anci to th€s extent set forth in applicable law.
MOSFORM-FULLPEOENROLLMENTPACK�` 3 @2020 MatrixOnesource
'0
Client Service A reement FOGA� MATRI
g � &ne5ource
A Vensure Employer Services Company
D. This Subsection III.D. applies only to worksites located in Florida. To the extent required by law and then
only for the limited purpose of enabling Matrix to fulfill its obligations under this Agreement, Matrix retains a right of
direction and control, which may or may not be exercised, over the management of safety, risk, and hazard control at
the worksite or sites affecting Leased Employees including: (i) responsibility for performing safety inspections of Client
equipment and premises, (ii) responsibility for the promulgation and administration of employment and safety policies,
and (iii) responsibility for the management of workers' compensation claims, claims filings, and related procedures. The
foregoing retention of right by Matrix does not require the actual exercise of such direction and control by Matrix at
the worksite at which or from which a Leased Employee works. Client acknowledges that (i) Matrix is required by law
in Florida to retain the foregoing right, which may or may not be exercised, and (ii) Client has actual control over each
worksite at which, or from which, Leased Employees work, and therefore, Client has the responsibility (i) to maintain
a safe working environment, (ii) to perform safety inspections of Client equipment and premises, (iii) to promulgate
and administer employment and safety policies, (iv) to provide proper training in compliance with state safety laws
and federal OSHA standards, and (v) to establish and maintain such safety programs, safety policies, and safety
committees as may be required by law. Further, notwithstanding Matrix's reservation of rights set forth hereinabove,
Client acknowledges that Matrix is not obligated to exercise any of such rights, Matrix assumes no liability merely as
a result of Matrix's reservation of such rights, and Matrix shall have no liability to Client, any Leased Employee, or any
third parry in the event Matrix fails, elects, or refuses to take any action to exercise any of such rights. Client agrees to
defend, indemnify, and hold Matrix harmless from any liability arising out of Client's failure to comply with or perform
any of the foregoing described responsibilities. Matrix shall provide, when requested by Client or deemed necessary by
Matrix, assistance in performing safety inspections of Client equipment and premises and assistance in the promulgation
and administration of employment and safety policies; however, Client acknowledges that it has the responsibility for
maintaining a safe work environment and for promulgating employment and safety policies. Client agrees to comply with
Matrix's workers' compensation light duty requirements and shall comply with such drug free workplace policies, if any,
as may be implemented by Matrix. Client agrees to immediately report to Matrix all injuries of Leased Employees. Client's
failure to immediately report an injury of a Leased Employee may cause a workers' compensation claim arising out of
such injury to be the responsibility of Client. In addition, Client's failure to timely report a claim may, in Matrix's discretion,
constitute a breach of this Agreement.
IV. BENEFIT PLANS; HEALTH CARE REFORM.
A. Client acknowledges that (i) Matrix does not provide employee benefit plans to any Client, (ii) Client is responsible
for securing and paying all benefit plans, and (iii) any employee benefit plans maintained by Client shall be the sole
responsibility of Client. In the event Client offers its own health benefits to Leased Employees ("Client Plans"), Client
shall be the sole plan sponsor and/or administrator of such plans. Client agrees that Client is solely responsible for (i)
establishing and monitoring any Client Plan under Client's own tax identification number, (ii) complying with all employee
notices, Form 5500s, plan updates, plan testing, HIPAA compliance, COBRA compliance, compliance with the Health
Care Reform Law, and compliance with ERISA requirements, and (iii) the correct identification and representation
of the Client Plans in any communication or statement issued by or on behalf of Client with regard to a Client Plan.
Client understands that Matrix only provides pre-tax administration for the Leased Employees that are covered by a
Client health plan. Matrix does not have any responsibility for the current COBRA participants on Client's group health
and life insurance plan in effect as of the effective date of this Agreement. Client has and will continue to assume full
responsibility for the continuation of coverage under COBRA for the current COBRA participants in addition to any
Leased Employees who may elect COBRA coverage under the Client's plan during the term of this Agreement, for the
remainder of their COBRA eligibility period.
B. Without limiting the foregoing, any penalties and liabilities assessed against or incurred by any Matrix Indemnified
Party (as hereinafter defined) arising out of or based upon a violation or alleged violation of the provisions of the Patient
Protection and Affordable Care Act of 2010, the Health Care Education Reconciliation Act of 2010, or any guidance
or regulation issued under any of the foregoing laws (collectively, the "Health Care Reform Law") with regard to any
Leased Employee are the sole obligation and responsibility of Client. in addition to any other indemnification provision
set forth in this Agreement, Client hereby unconditionally agrees to defend, indemnify, and hold the Matrix Indemnified
MOSFORM-FULLPEOENROLLMENTPACK 4 92020 MatrixOneSource
`0
Client Service Agreement FUGA M ANT R 11
g & n e S o u r c e
A Vensure Employer Services Gompany
Parties harmless from, and unconditionally releases, acquits, waives, and forever discharges (and agrees not to sue) all
Matrix Indemnified Parties from and against, any and all penalties and liabilities assessed against any Matrix Indemnified
Party or incurred by a Matrix Indemnified Party as a result of an actual or alleged violation of the Health Care Reform
Law. Without limiting the foregoing, in the event that any penalties are assessed or liabilities are incurred by any Matrix
indemnified Party that are based upon or arise out of (i) the provision of incorrect information by Client to Matrix, or (ii)
the failure of Client to provide Matrix with required information, which in turn was included on or omitted (due to Client's
failure to provide) from reports or returns prepared by Matrix including, but not limited to, any Form W-2, Client agrees to
defend, indemnify, and hold the Matrix Indemnified Parties harmless from any such penalty or liability.
V. SERVICE FEES.
A. For services rendered under this Agreement, Matrix shall be entitled to a set-up fee and service fee as specified
on an Exhibit hereto. All funds due Matrix are payable by wire transfer, certified check or company check (for
approved clients) prior to Matrix's issuance of payroll checks or payroll deposits and prior to the delivery of such
checks or deposits each pay period. A late payment charge of one and one-half percent (1 1/2%) will be added
to all accounts not paid when due. Checks returned unpaid from Client's bank will be subject to the late payment
charge plus any additional costs incurred by Matrix. Client agrees to replace any returned checks with certified
funds prior to Client's next pay period. Client will then be placed on certified funds for a period of at least ninety (90)
days. An unpaid balance will also be subject to periodic charge of one and one-half percent (1 1/2%) per calendar
month (or such lesser rate if required by law) until paid in full. Matrix reserves the right to, at any time, terminate
this Agreement if full payment is not made when due. In addition, certificates of insurance issued by Matrix or its
workers' compensation insurance carrier will be canceled immediately and all certificate holders will be immediately
notified of such cancellation.
B. If Client requires additional services not included in this Agreement, the fee for any such additional services shall
be negotiated and paid separately. The fees set forth on an Exhibit hereto are subject to adjustment by Matrix at
any time in its sole discretion based upon changes in local, state and/or federal employment law, costs directly or
indirectly attributable to Client, changes in Client's payroll, or any other factor that Matrix believes in its discretion
necessitates a fee or rate adjustment to Client. Client shall have the right to terminate this Agreement by giving
notice of termination to Matrix within fourteen (14) days after a service fee adjustment and after payment of all
funds owed to Matrix by Client.
C. If both Client and Matrix are agreeable to allowing Client to pay amounts under this Agreement to Matrix by company
check, Client shall, if required by Matrix, maintain a prepayment with Matrix in an amount equal to the total payroll
and any direct and indirect costs related to that payroll for one average payroll period. Any such prepayment shall
be maintained by Matrix to help guarantee performance of all terms, covenants, and obligations of Client under this
Agreement. If Client should fail to pay Matrix any payment when due, Matrix may apply the prepayment to the amount
due. Matrix shall refund any remaining prepayment within thirty (30) days after the termination of this Agreement provided
Client has fulfilled all of its obligations under this Agreement. If CLEINT pays Matrix amounts under this Agreement by
company check and any such check is returned NSF or insufficient funds, CLEINT will immediately be placed on certified
funds or wired funds for a minimum period of ninety (90) days.
VI. LIMITATIONS OF SERVICES.
A. Matrix shah only provide the services described herein. No other services shall be provided or be implied to be
provided by Matrix including, without limitation, any strategic, operational, or other business related decisions with
regard to Client's business. Matrix shall not be liable for Client's loss of business goodwill, profits, or other consequential,
special, or incidental damages, and Client shall hold Matrix and its shareholders, attorneys, officers, directors, agents,
and representatives harmless for any such losses.
B. The records provided by Client will be the basis for Matrix to isauo all payroll checks and make payroll deposits_
Matrix shall not be responsible for incorrect, improper, or fraudulent records of hours worked, for the improper
MOSFORM-FULLPEOENROLLMENTPACK 4 5 @2020 MatrixOneSourcP
'0
Client Service Agreement FUGA) MATR P
g I n e S o u r c e
A Vensure Employer Services Company
determination of exempt or overtime status or workers' compensation classifications, or for any damages sustained
by Client as a result of Matrix's issuance of payroll checks or payroll deposits in reliance on erroneous or incomplete
information submitted by Client. In addition, except as required by applicable state or federal law, Matrix shall not be
considered a co -employer of any individual for whom payroll information is not timely supplied by Client for any given
payroll period. Client understands that Matrix's responsibility and liability its specifically limited and conditioned upon
receipt of complete and accurate information from Client, the timeliness of same, and Client's compliance with its
payment obligations under this Agreement.
C. The records provided by Client will be the basis for Matrix to issue all payroll checks and make payroll deposits.
Matrix shall not be responsible for incorrect, improper, or fraudulent records of hours worked, for the improper
determination of exempt or overtime status or workers' compensation classifications, or for any damages sustained
by Client as a result of Matrix's issuance of payroll checks or payroll deposits in reliance on erroneous or incomplete
information submitted by Client. In addition, except as required by applicable state or federal law, Matrix shall not be
considered a co -employer of any individual for whom payroll information is not timely supplied by Client for any given
payroll period. Client understands that Matrix's responsibility and liability is specifically limited and conditioned upon
receipt of complete and accurate information from Client, the timeliness of same, and Client's compliance with its
payment obligations under this Agreement.
D. Matrix shall not be considered an employer of any Leased Employee for purposes of compliance with the completion
and retention of 1-9 Forms. Client acknowledges that Leased Employees will only be performing labor and/or services for
Client and not for Matrix.
E. Matrix does not assume any responsibility to perform any background checks or investigation on any Leased Employee in
accordance with any federal, state, or local law, and Matrix makes no assurances, warranties, or guarantees as to the ability or
competence of any Leased Employee. Client specifically assumes responsibility to perform any and all work history, reference
checks and background checks on Leased Employees, and likewise assumes and agrees to defend, indemnify, and hold
Matrix harmless for any liability associated with the negligent hiring or retention of any Leased Employee.
F Client acknowledges and agrees that Matrix is not engaged in the practice of law or the provision of legal services, and
that Client alone is completely and independently responsible for its own legal rights and obligations.
VIi. INDEMNIFICATIONS
Client will provide proof of comprehensive general liability insurance coverage for its operations and all employees,
whether leased or not, with a limit of liability of not less than one million dollars ($1,000,000.00) per occurrence. If any
Leased Employee will operate a vehicle (whether owned, leased, or borrowed) of any kind while working for Client.
Client shall furnish liability insurance therefore against liability for bodily injury and property damage and against
uninsured motorists, each with a minimum limit of liability of not less than one million dollars ($1,000,000.00). Such
policies shall also include blanket collateral liability and personal injury liability coverage. In addition, if professional
employees are leased, professional liability coverage must be secured and maintained by Client with a limit of
liability of not less than one million dollars ($1,000,000.00). Client agrees, at its own expense, to include Matrix as
an additional named insured on all of Client's insurance policies, including without limitation, its general liability,
auto liability, and professional liability policies and fidelity bonds. All policies of insurance required to be maintained
by Client under this Agreement shall provide that the insurer shall not be permitted to cancel such insurance policy
without providing at least twenty (20) days written notice of cancellation to Matrix. Client shall, at the request of
Matrix, deliver to Matrix a certificate evidencing the insurance policies required by this Agreement. Client waives any
claim in its flavor against Matrix by way of subrogation, and all insurance policies maintained by Client shall waive
such subrogation rights. Any protection against the dishonest or criminal conduct or misappropriation of any funds
engaged in by any Leased Employee maintained hereunder, such as fidelity bonding, shall be at Client's expense.
Client's obligations under thio OQotion shall ourvive termination of this Agreement.
MOSFORM-FULLPEOENROLLMENTPACK 6 02020 MatrixOneSource
'0
Agreement (FUGA) ATR'
Client Service A
g 41neSource
A Vensure Employer Services Company
Vlll. INDEMNIFICATIONS
A. In addition to any other indemnifications set forth in this Agreement, Client shall unconditionally defend, indemnify,
and hold harmless Matrix and all Affiliates (as hereinafter defined) thereof, and all of the shareholders, directors, officers,
employees (other than Leased Employees of Client), attorneys, agents, and representatives (ail of the foregoing are
hereinafter referred to as the "Matrix Indemnified Parties") from and against any and all claims, demands, damages
(including liquidated, punitive, and compensatory), injuries, deaths, actions and causes of action, costs, and expenses
(including attorney's fees and expenses at all levels of proceedings), losses and liabilities of whatever nature (including
liability to third parties) (collectively, the "Claims"), without regard to the negligence of a Matrix Indemnified Party, that
are based upon or arising out of, any intentional, reckless, or negligent act or omission of Client, any Affiliate thereof, or
any shareholder, director, officer, employee (including Leased Employees), attorney, agent, representative, independent
contractor, subcontractor, or person working by, for, or under the direction or control of, Client or any Affiliate thereof
(collectively, the "Client Parties"), including, but not limited to, Claims based upon or arising out of:
1. Breach of contract, criminal or dishonest activity, actions or incidents covered by all liability policies,
professional liability policies, and fidelity bonds as required to be maintained by Client under this
Agreement, costs attendant to the administration of any collective bargaining agreement, and any liabilities
or claims arising out of any non-payment or payment to or participation in a labor organization's health
and welfare retirement or other benefit fund, including the cessation of payment thereto or withdrawal from
participation therein;
2. The Employment Laws or any other employment related matter, whether or not such other employment related
matter is based upon or arises out of the violation of a federal, state, or local law, regulation, rule, or ordinance;
3. Any other federal, state, or local law, rule, regulation, or ordinance:
4. Any claims or actions arising out of, occasioned by, or in connection with, (i) Client's failure to strictly comply
with any obligation of Client arising out of this Agreement including, without limitation, any obligation of
Client set forth in Article IX of this Agreement, and (ii) those arising from products or services (professional or
otherwise) produced or provided by a Client Party;
5. Client's use of any Leased Employee or any other employee, independent contractor, or subcontractor;
6. Client's real or personal property including, but not limited to, Client's machinery, facilities, equipment and/or
vehicles, whether leased, rented, borrowed or owned;
7. Injuries occurring to any individual performing work for, on behalf or at the request of, or under the direction or
control of,Client, other than a Leased Employee, whether or not Client retained its own workers' compensation
policy covering such injuries, and any acts of negligence by or towards any Leased Employee that are beyond
the coverage of workers' compensation coverage;
8. Benefits paid and expenses incurred by Matrix or its workers' compensation carrier as a result of a workers'
compensation claim of a Leased Employee arising out of an injury incurred during a period where Client did not
timely report payroll hours for such Leased Employee;
9. Benefits paid and expenses incurred by Matrix or its workers' compensation carrier as a result of workers'
compensation claims of any Leased Employees arising out of injuries incurred while such Leased Employees
were performing job functions that are beyond the scope of the workers' compensation classifications set forth
on an Exhibit to this Agreement- and
10. The failure of Client's subcontractors and 'independent contractors to maintain workers' compensation
Goverage, including workers' compensation claims of any employees of such contractors_
MOSFORM-FULLPEOENROLLMENTPACK 7 02020 MatrixOneSource
'0
Client Service Agreement (FOGA) NI ATRI;
g Ine5ource
A Vensure Employer Services Gompany
B. Matrix hereby agrees to unconditionally indemnify, hold harmless, protect and defend Client, and all affiliated entities,
and all of their shareholders, employees, attorneys, officers, directors, agents and representatives from and against any and
all claims demands damages, injuries, deaths, actions, costs and expenses (including attorney's fees and expenses at all
levels of proceedings), losses and liabilities of whatever nature (including liability to third parties), and other consequences
of any sort, arising out of the negligent or willful failure of any non -leased employee employed by Matrix at its corporate
office to comply with applicable workers' compensation, withholding tax, or ERISA laws, rules and regulations.
C. All indemnifications shall survive the termination of this Agreement. An "Affiliate" of any individual person,
corporation, limited liability company, or other entity (collectively a "Person") means any Person directly or indirectly
controlling, controlled by, or under common control with, such Person.
IX. CLIENT OBLIGATIONS AND RIGHTS.
A. Client shall be responsible for all of the terms and conditions of employment of Leased Employees including, but not
limited to, the terms and conditions of the aspects of employment set forth in Section VLC of this Agreement. Client has
the right to accept or cancel the assignment of any Leased Employee. Client agrees that in making such decisions it will
at all times comply with all applicable laws. If Client terminates the assignment or employment of a Leased Employee, or
if a Leased Employee resigns from employment with Client, Client shall immediately give Matrix written notice thereof.
B. Client agrees that it will obtain and provide to Matrix at the end of each pay period records of actual time worked by
each Leased Employee, determine and verify each Leased Employee's exempt or non-exempt status, and verify that all
hours worked by Leased Employees that are reported to Matrix are accurate and are in accordance with the requirements
of the Fair Labor Standards Act and other laws administered by the U.S. Department of Labor's Wage and Hour Division
and any applicable state law. The information and records submitted by Client to Matrix shall become the basis for Matrix
to issue all payroll checks and make payroll deposits. Matrix shall not be responsible for incorrect, improper, or fraudulent
records of hours worked, or for improper determination of exempt status. If Client fails to meet the processing and
payment schedule required by Matrix, the delivery of payroll checks and payroll deposits by Matrix will be delayed and an
out of cycle processing charge may be billed to Client at Matrix's option. Similarly, any changes to the hours reported to
Matrix after the reporting time could be subject to an out of cycle processing charge at Matrix's option.
C. Client shall comply with all local, state and federal employment-related laws and regulations, including but not limited
to: wage and hour laws including, without limitation, prevailing wage rate, exempt and non-exempt status, child labor,
and minimum wage and overtime matters, and the Fair Labor Standards Act ("FLSA"); Immigration and Nationality
Act ("INA"); right -to -know laws; environmental laws; the National Labor Relations Act; Occupational Safety and Health
Act ("OSHA"); Worker Adjustment and Retraining Notification Act ("WARN"); and all other laws, rules and regulations
governing race, sex, sexual harassment, retaliation, religion, national origin, color, age, veteran status, disability, marital
status and union status or discrimination based on any of the foregoing or other protected classes; public access
and public accommodation including, but not limited to, the Americans with Disabilities Act ("ADA"); Family and
Medical Leave Act ("FMLA"); Employee Retirement Income Security Act, ("ERISA"); Health Insurance Portability and
Accountability Act, ("HIPAA"); Sarbanes—Oxley Act of 2002; all privacy laws and regulations; the Fair and Accurate Credit
Transactions Act of 2003; all laws governing disclosed and undisclosed benefit plans; any other law, rule, or regulation
administered by the Federal Department of Labor or the Equal Employment Opportunity Commission; and all other
federal, state, and local labor and employment laws, rules, and regulations (collectively, the "Employment Laws").
D. Client, at Client's expense, (i) shall provide all Leased Employees with a safe working environment and proper training
in compliance with OSHA and all other federal, state, and local laws, (ii) shall provide and ensure the use of all personal
protective equipment, and (iii) shall comply with all health and safety laws, recommendations, directives and rules, safety
programs, and safety policies as may be required or imposed by any governmental agencies with jurisdiction thereof,
by Matrix, or by any workers' compensation carrier covering Leased Employees. Client represents that its working
environment, equipment, macninery, supplies and training for existing employees currently meet all s#ate and federal
OSHA standards and that they will be maintained in compliance with such standards.
MOSFORM-FULLPEOENROLLMENTPACK 8 32020 MatrixOneSource
0
M RClient Service Agreement (FUGA)
4neSource
A Vensure Employer Services Company
E. All employers in the United States are required by federal law to verify the employment authorization and identity
of each person they hire. Client acknowledges (i) that Client shall be responsible for complying with this requirement
by obtaining and completing an Employment Eligibility Verification Form 1-9 ("Form 1-9" or "11-9 Form") for each
Leased Employee and retaining such form in compliance with the requirements of the INA, and (ii) that Matrix is not be
responsible for obtaining, completing, or retaining a Form 1-9 for any Leased Employee. Client agrees not to allow any
Leased Employee to provide any labor or services for Client prior to the time that Client obtains and completes a Form
1-9 for such Leased Employee. For each Leased Employee, Client agrees to retain completed Form 1-9s for a period of
three (3) years from the date of employment or one (1) year from the date of termination of employment, whichever is
later, or for any other period as prescribed by INA regulations, as they may change from time to time. As a service to
Client, Matrix may offer to retain on Client's behalf possession of the 1-9 Forms obtained by Client for Leased Employees.
If Matrix offers to do so, Client acknowledges that this service is merely an administrative function limited simply to
the retention of such records on Client's behalf, and that by doing so, Matrix accepts no responsibility for the proper
completion, review, or verification of information contained in any such documents retained. Client may be asked to
complete and execute a document confirming (i) Client's request for Matrix to retain possession of 1-9 Forms, and (ii)
Client's agreement to the terms hereof.
F. Client shall immediately report to Matrix all employment-related complaints, allegations or incidents, (regardless of the
source and whether or not they affect Leased Employees), of any tortious misconduct, workplace safety violations, and
employment misconduct, including but not limited to any allegations of sexual harassment or discrimination of any kind.
Client shall also provide Matrix complete and accurate details of all circumstances surrounding such matters.
G. Control over the day-to-day job duties of Assigned Employees and over the job site at which, or from which, Leased
Employees perform their services is solely and exclusively assigned to and assumed by Client. Client will provide all
facilities, supplies, equipment, including safety equipment, training, and all other necessary items that may be required
by Leased Employees to perform their job functions in a safe manner. Client shall also make all strategic, operational,
and all other business-related decisions regarding Client's business. Such decisions and related outcomes shall
exclusively be the responsibility of Client and Matrix shall bear no responsibility or liability for any actions or inactions by
Client or by any Leased Employee.
H. Client acknowledges that it is essential to Matrix's performance under this Agreement that Matrix have complete
knowledge of any government investigation or inquiry or private adversarial action which could in any manner impact
upon the types of duties contemplated by this Agreement. Client confirms that it has disclosed in writing to Matrix any
such investigation, action, lawsuit, or proceeding (including, but not limited to, those conducted by the EEOC, NLRB,
OSHA, U.S. Department of Labor, or those involving the FLSA), including those which have been threatened as well as
those not yet asserted, involving or threatened to involve Client, during the last five (5) years.
X. BREACH AND TERMINATION.
A. Matrix shall have the right to immediately terminate this Agreement if: (i) any payment required to be made
by Client under this Agreement is not made when due; (ii) Client fails to properly report all time worked by each
Leased Employee; (Iii) Client flailed or fails to disclose all information regarding the nature of work duties, business
operations, and locations of workers; (iv) Client fails to immediately report any injury of any Leased Employee; (v)
Matrix determines in its sole discretion that a material adverse change has occurred in the financial condition, of
Client, or that Client is unable to pay its debts as they become due in the ordinary course of business; (vi) upon the
occurrence of any federal, state, or local law, regulatory action, or judicial decision which, at the sole discretion of
Matrix, adversely affects its interest under this Agreement; or (vii) Client fails to comply with any provision of this
Agreement or any written policy of Matrix.
S. airrlultaneousiy with the termination Of this AEjrooment for any mason, (i) c=aeh Leased Emplayee's emplovment
with Matrix shall automatically terminate, (ii) each Leased Employee shall automatically become solely employed by
MOSFORM-FULLPEOENROLLMENTPACK 9 @2020 MatrixOneSource
Service A FUGA M A:Tr R i t�
'0
Client Ser Agreement g t &neSource
A Vensure Employer Services Company
Client, and (iii) Client shall give notice to each Leased Employee (a) of the termination of this Agreement, (b) that they
are no longer a Leased Employee of Matrix, (c) that they are no longer covered by Matrix's workers' compensation
insurance policy, and (d) that they are solely employed by Client. Matrix may, at its option, provide the foregoing notice
to Leased Employees, but any such notice shall not relieve Client of its obligation to provide such notice. Client shall
immediately assume all federal, state, and local obligations of an employer to the terminated Leased Employees and
shall immediately assume full responsibility for providing workers' compensation coverage. Matrix shall immediately
be released from such obligations to the fullest extent permitted by law. If for any reason (whether or not required by
applicable law) Matrix makes any payment to any of the Leased Employees after this Agreement has been terminated,
Matrix shall be entitled to full reimbursement from the Leased Employee and from Client for such payments. The
termination of this Agreement shall not relieve Client of any obligation set forth herein including, but not limited to, its
payment obligations to Matrix.
XI. GENERAL PROVISIONS; MISCELLANEOUS.
A. Client acknowledges that it has not been induced to enter into this Agreement by any representation or warranty
not set forth in this Agreement including, but not limited to, any statement made by any employee of Matrix or any
independent broker or marketing agent. Client acknowledges that Matrix has made no representation concerning
whether Matrix's services will improve the performance of Client's business.
B. Client specifically authorizes Matrix to conduct a credit and background reference check on Client and such officers of
Client as Matrix deems appropriate.
C. Client may not assign this Agreement nor any of its rights or duties hereunder, or any interest herein, without the prior
written consent of Matrix. Matrix and its assigns may freely assign this Agreement any number of times at any time to
any entity, whether or not affiliated with Matrix, without notice to Client, and in such event, Matrix, or any other assignor
hereof, shall have no further liability or obligations under this Agreement.
D. All provisions of this Agreement that by their nature are intended to survive including, but not limited to,
disclaimers of warranties, confidentiality obligations, limitations of liability, and indemnifications, shall survive the
termination of this Agreement
E. This Agreement constitutes the entire agreement between the parties with regard to this subject matter hereof, and no
other agreement, statement, promise or practice between the parties relating to the subject matter shall be binding on
the parties. This Agreement may be changed only by a written amendment signed by both parties.
F. The failure by either party at any time to require strict performance by the other party or to claim a breach of any
provision of this Agreement will not be construed as a waiver of any subsequent breach nor affect the effectiveness of
this Agreement, or any part thereof, or prejudice either party as regards to any subsequent action.
G. After execution of this Agreement by Client, this Agreement shall be delivered to Matrix in Duval County, Florida for
execution by Matrix. This Agreement shall be governed by and construed in accordance with the laws of the State of
Florida, and venue for any action arising out of or in connection with this Agreement shall be exclusively in federal or
state court located in Duval County, Florida. The parties hereby consent to the personal jurisdiction of such courts.
H. In the event of any lawsuit or other proceeding to enforce the provisions of this Agreement, the prevailing party shall
be entitled to an award of its costs and reasonable attorney's fees incurred at all levels of proceedings.
I. Any notice or demand given hereunder shall be accomplished by the personal delivery in writing or by other delivery with
proof of delivery or attempted delivery to the address set forth herein for the other party, and shall be deemed effective
upon proof of attempted delivery (actual delivery to be made as soon as is practicable following attempted delivery).
MOSFORM-FULLPEOENROLLMENTPACK 10 @2020 MatrlxOneSource
nt Service Agreement FUGA �� R
Clie g ( )
i1nnource
A Vensure Employer Services Company
J. No rights of any third party are created by this Agreement and no person that is not a party to this Agreement may rely
on any aspect of this Agreement.
K. In the event that any provision contained in this Agreement is held to be unenforceable by a court of competent
jurisdiction, the validity or enforceability of the remainder of this Agreement shall in no way be affected or impaired thereby.
L. This Agreement shall be valid and enforceable only upon the signature below by an authorized Controlling Person of Matrix.
REPRESENTATION REGARDING AMOUNTS OWED:
Client represents and warrants that it does not owe (i) any current or prior employee leasing company amounts under a
service agreement or (ii) any current or prior insurance company any premium for workers' compensation insurance. If
Client is located or has employees in the state of Florida, Florida law provides that Client shall not enter into an employee
leasing relationship or be eligible for workers' compensation coverage from an insurer if Client owes amounts to any
employee leasing company or premium for workers' compensation insurance to any insurer.
Effective as of the effective date indicated and written by an authorized Matrix representative below.
Client Business Name: Valrose Investment Group LLC
Client Representative Name:
Client Representative SignatL
Title: Owner nate:
INFORMATION BELOW MUST BE COMPLETED BY OR ON BEHALF OF CLIENT::
DBA of Client:
(if Client does business under a name other than its legal name (i.e. a trade name), print D/B/A above)
Client's FEIN: 87-3780349
Georgia Only: Client's Georgia Department of Labor Account No.::
Physical Address of Client:
4450 E. 11 th Ave
Hialeah FL 33013
MATRIXONESOURCE:
a d/b/a of:
By:
Print Name:
Title:
MOSFORM-FULLPEOENROLLMENTPACK
III
Mailing Address (if different from Physical Address):
Date:
@2020 MatrixOneSource
"o
MATRClient Service Agreement(FOGA)
IneSQurce
A Vensure Employer Services Company
GUARANTY AGREEMENT
To induce MATRIXONESOURCE, or any other entity affiliated therewith (including their successors and assigns, collectively
"Matrix"), to enter into a Client Service Agreement and otherwise extend credit to Valrose investment GroupLLC LC ("Client"),
the undersigned (jointly and severally "Guarantor") hereby unconditionally guarantees the full payment and performance
of any and all obligations and indebtedness of the Client to Matrix under the Client Service Agreement (collectively, the
"Obligations"). Guarantor agrees to pay and discharge each Obligation of Client to Matrix when due, by acceleration or
otherwise, in accordance with the terms of the Client Service Agreement between them, and hereby waives all notice
of acceptance of this Guaranty, notice of maturity, payment or default of any Obligation, and any other requirement or
notice necessary to bind it hereunder including, but not limited to, presentment, notice of dishonor, and notice of protest.
Guarantor also agrees to pay all costs (including attorney's fees incurred in collection, trial and appeal) of collection
against Guarantor under this Guaranty.
The liability of Guarantor hereunder applies irrespective of the genuineness, validity, regularity or enforceability of any
instruments or contracts evidencing, relating to or securing the Obligations of Client, and Guarantor hereby consents that
from time to time Matrix may, without notice to Guarantor and without affecting any liability of Guarantor hereunder, (a)
exchange, release, sell, apply or otherwise deal with any collateral that may have been given to secure the Obligations,
(b) extend, renew or accelerate the Obligations in whole or in part, or (c) waive or fail to enforce any of its rights under
any instruments evidencing, relating to or securing the Obligations.
The liability of Guarantor hereunder is binding upon Guarantor and Guarantor's successors and assigns. The revocation
of this Guaranty shall not relieve Guarantor of any liability for any Obligations arising prior to Matrix's receipt of written
revocation hereof, or any renewal or extension thereof.
The term "Obligations," as used herein, shall mean all obligations of Client to Matrix, whether now or hereafter due
or arising, including without limitation all principal and interest, all costs of collection, including reasonable attorney's
fees, whether incurred in connection with collection, trial, appeal or otherwise, all other amounts which Client is
obligated to pay Matrix under any instruments or contract evidencing, relating to or securing the Obligations or any
part thereof. In the event any part of the Obligations is paid by Client and because of any bankruptcy or other laws
relating to creditor rights, Matrix is required to repay any amounts to Client or to any trustee, receiver or otherwise,
then the amount so repaid shall again become part of the Obligations, the repayment of which is guaranteed hereby.
IN WITNESS WHEREOF, Guarantor(s) has caused this instrument to be executed as of the .2nd day of , Jjdaroh_
2022 (insert Date).
*The term "Obligations" specifically includes, but is not limited to, any obligation of Client to Matrix under that certain
Client Service Agreement between Client and Matrix.
Guarantor:
Signature: -�
Name: Jason Gu#man
Guarantor:
Signature:
Name:
MOSFORM-FULLPEOENROLLMENTPACK
Witness to Guarantor's Signature
Signature:
Name:
Witness to Guarantor's Signature
Signature:
Name:
12
@2020 MatrixOneSource
'0
Credit Report Authorization and Release MATRI
4neSource
A Vensure Employer Services Company
I hereby authorize any individual, company or institution (the "Releasing Party") to release to Matrix and any affiliate
thereof, and any of their representatives or assigns (collectively, "Matrix"), any information the Releasing Party has
regarding my credit and/or credit history. Authorization is hereby granted to Matrix to obtain a standard factual data
credit report through one or more credit reporting agency chosen by Matrix.
My signature below authorizes the release to Matrix of a copy of any of my credit applications and authorizes Matrix to
obtain information regarding my employment, saving accounts, and outstanding credit accounts (mortgage loans, auto
loans, personal loans, charge cards, credit unions, etc.). Authorization is further granted to Matrix to use a reproduction
of this authorization to obtain any of the above-described information.
Any reproduction of this Credit Report Authorization and Release (for example, photocopy or facsimile) shall be
considered an original.
I hereby release the Releasing Party and all employees, agents, or representatives connected therewith from all liability
from any damage whatsoever incurred in furnishing such information.
This Authorization is for the purpose of obtaining business credit, and is not for obtaining consumer credit.
Guarantor Name:
Guarantor Signature:
Home Address: 18911 Collins Avenue Apt 3406
City: Sunny Isles Beach State: Florida ZIP: 33160
Date: 03/02/2022 Social Security Number: 593902571 Date of Birth: 11191986
Date: 03/02/2022 FEIN Number: 87-3780349 ($35.00 Fee for Business Credit)
Co -Guarantor Name:
Co -Guarantor Signature: _
Home Address:
City:
Date -
State:
Social Security Number:
Date of Birth:
MOSFORM-FULLPEOENROLLMENTPACK 13 02020 MatrixOneScume
'0
h rization to Verify Bank Deposit History M AT R I
Auto Y p Y 4,neSource
A Vere Employer Services Company
Client Name_ Valmse Investment Group
Client FEIN or Owner's SSN: 87-3780349
Name of Bank: Wells Farpo
Contact Person: Daniel Rivera
Bank Street Address: 461 From Road Suite 235
Bank City, State, and ZIP: Paramus. NJ 07652
Bank Telephone Number: 201.226.3042 Bank Fax:
Do you have multiple accounts with this bank (check ane)? Yes ❑✓ No
If yes, please record all accounts you wish to have considered:
1. Name(s) on Account:
Account Number:
2. Name(s) on Account:
Account Number:
3. Name(s) on Account:
Account Number:
Purpose:
Purpose:
Purpose:
I authorize the release of information regarding the above listed accounts to Matrix or any affiliate thereof for the
purposes of credit investigation for business puToses.
Signature (Signatory on above Accounts):
Printed Name of Signatory on above Accounts: Jason Gutman
DO NOT WRITE BELOW THIS AREA — FOR INTERNAL AND BANK USE ONLY
Date Account 1 Was Opened:
# of NSF Checks Since Account Was Opened:
Date Account 2 Was Opened:
# of NSF Checks Since Account Was Opened:
Date Account 3 Was Opened:
# of NSF Checks Since Account Was Opened:
Name of Bank Rep:
MOSFORM-FULLPEOENROLLMENTPAGK
Average Daily Balance:
Last 12 Months:
Average Daily Balance:
Last 12 Months:
Average Daily Balance:
Last 12 Months:
Phone and Ext. :
14
02020 MatrixOneSource
'0""
Authorization to Honor Items Debited MNTR�
dne5ource
A Vensure Employer Services Company
Name of Depositor as shown on Bank Records: Valrose Investment Group
If Depositor is a Corp./LLC/Sole Proprietorship/Other Entity — Print Name of Authorized Signatory:
Valrose Investment Group
Account Number: 3397544697
Bank Name:
Bank Address: 461 From Road, Suite 235
Bank Contact: Daniel Rivera
I hereby authorize MATRIX, or any affiliate thereof, to debit the above- referenced account each week to pay for my
employee leasing services. No debit shall exceed the amount shown on the weekly invoice that details our weekly
payroll, FICA taxes, FUTA taxes, SUI taxes, workers' compensation and management/administrative fee, health care,
dental or other benefits (401(k), etc.), and insurance premiums.
Any debit that is returned for any reason will require payment in the form of a cashier check for future payrolls.
Depositor/Company Name: Valrose Investment Group
Signature of Authorized Signatory on Account:
Address: 18911 Collins Avenue, Apt 3406 Miami, Florida 33160
Date: 03/02/2022
ATTACH A VOIDED CHECK BELOW ON THE ACCOUNT OR ACCOUNTS THAT WILL BE DEBITED
MOSFORM-FULLPEOENROLLMENTPACK
15
@2020 MatrixOrieSource
'0
Class Code Affidavit M ATR1**
4neSource
A Vensure Employer Services CompaM
This form will address class codes that are commonly miscoded in construction and industrial operations. Miscoding is the
intentional or unintentional use and assignment of a class code. They include the following:
• 5606: Contractor -Project Manager, Construction Executive, Construction Manager, or Construction Superintendent
8742 - DE951: Salespersons or Collectors -Outside
• 8809 (TX -ONLY): Executive Officers NOC-Performing Clerical or Outside Salespersons Duties Only
• 8810 - DE953: Clerical Office Employees NOC
Please read the following abbreviated NCCI Scopes definitions to understand what is and is not applicable to their
assignment. The complete NCCI Scopes Manual description will be provided to you by your PEO provider upon request.
Please select, with an X, the Class Code(s) you are requesting be assigned to a co -employee assigned to your business:
❑5606: This classification is available only to project managers, construction executives, construction managers, or
constructionsuperintendents having administrative or managerial responsibility for construction or erection projects.
When determining eligibility.it is the job duties, and not the job titles, that are the main consideration. Code 5606 does
not apply to any person who is directly incharge of, or who is performing any degree of actual construction work. Such
person must be assigned to the classification thatspecifically describes the type of work which they are exercising direct
supervisory control. A sole proprietor or owner/operator withno employees, working as a subcontractor for the Client
Company, would prevent the assignment of this classification to a constructionexecutive because the subcontractor
does not have the required job supervisor or foreman to support indirect supervision.
8742 - DE951: Salespersons or collectors are employees engaged in such duties away from the employer's premises.
8742 is notavailable for employees who deliver merchandise. Judgment is necessary in assessing these employees'
duties for classificationpurposes since occasional courtesy deliveries of a nominal quantity of merchandise would not
preclude them from being classified to8742. When outside salespersons or collectors regularly and frequently perform
duties at the premises of their employers, their totalpayroll is assigned to the highest rated classification representing any
part of their work.
8809 (TX -ONLY): Executive Officers performing clerical or outside salespersons duties only - not superintendents, foremen
orworkers. This classification applies only to executive officers such as the president, vice president, secretary, treasurer or
any otherofficer appointed in accordance with the charter or by-laws of the corporation or a professional association.
®8810 - DE953: This classification is available only to clerical/ administrative personnel whose work areas are separated
anddistinguishable from all other work areas and hazards of the employer by floors, walls, partitions, counters, or other
physical barriers.The duties of a clerical office employee include creation or maintenance of financial or other employer
records, handlingcorrespondence, computer composition, technical drafting, and telephone duties, including sales by
phone. The clerical office classification continues to apply to a qualified clerical office employee who performs a duty
outside of a qualified clerical office areawhen that duty does not involve direct supervision or physical labor and is
directly related to that employee's duties in the office.
Activities prohibited while assigned to the codes listed above include: delivering, carrying and loading of any work related
materials/equipment. Deliveries of a nominal or insignificant quantities by an employee assigned to 8742 is appropriate_
Climbing ladders, operating equipment, quoting work off the ground or on roofs and all other physically demanding work is
also prohibited.
Ally HR, LLC reserves the right to retroactively apply all payroll for miscoded employees in any policy period when a
determination is made that miscoding has occurred. Miscoded employees will be assigned to the highest rated/governing
construction code.
By signing this affidavit, I am certifying that I have read the full description of the applicable code, as outlined in the National
Council on Compensation Insurance (NCCI) Scopes Manual, and that all employees assigned in the aforementioned code(s)
are properly classified.
Client Company Name: i/alrnce Investment Gmup_I I C PEO Provider Name: MatrixOneSource
Client Owner Name: Jason i utman Client Owner Signature: `""' Date: g /21122
Any person who knowingly and with intent to defraud any insurance company or another person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading
information concerning any fact material tnereto, commits a fraudulent insurance act, which it a crime and subjects the person
to criminal and civil penalties.
MOSFORM-FULLPEOENROLLMENTPAOK 16 @2020 MatrixOneSource
A11v H R LLC Loss Histo Affidavit A►'�' R
Y neSoy rce
A Vensure Employer Services Company=
This affidavit shall be utilized to validate and acknowledge a prospective company's workers' compensation loss
experience, or the lack thereof, when Carrier, PEO and/or Payroll Company generated loss runs or declarations are
not being presented.
This affidavit must be completed by an owner/officer.
COMPANY INFORMATION
1, Jason Gutman _ 1 (Print Owner/Officer Name) certify that Vairose Investment Group I LC (Company LegalName) and any related business entities through common ownership/ interest, as well as any predecessor companies
listed below, if any: (Common Ownership/Related Entities),
LOSS HISTORY ACKNOWLEDGEMENT
has not experienced any work related injuries and/or reported any workers' compensation claims and certifythat
no current or former employees have reported an injury in the prior 3 years from the date this form is signed.
0 has experienced work related injuries and/or reported workers' compensation claims in the prior 3 years.
PRESENT ALL(**) INJURIES AND DETAILS BELOW:
**If more claims exists, within the prior 3 year period, please present on another sheet of paper using the same format.
It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation
transaction for the purpose of committing fraud. Penalties include imprisonment, fines, and denial of insurance benefits.
Any person who knowingly, and with intent to defraud any insurance company or another person, files an application
for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the
person to criminal and civil p nalties.
Owner/Officer Signature: Title/Position: Owner Date: 03/0212022
PEO REPRESENTATIVE ACKNOWLEDGEMENT
I attest that I have counseled the aforementioned business owner/ officer regarding the presentation of loss data for underwriting.
Owner/Officer Signature: MatrixOneSource Date: 03/02/2022
PEO Representative Name: Thomas A Deming Signature:
MOSFORM-FULLPEOENROLLMENTPACK 17 92020 MatrixOneSoure
Client Set Up Sheet
Client Name:Valrose Investment Group LLC
Payroll Contact:Fabiana Nudelman
Payroll Email:fabiana@valrose.com
Street Address: 4450 E. 11 th Ave
Delivery Address: 4450 E. 11th Ave
Office Number: (305) 893-5553
Cell Phone:
Matrix to Retain Employee 1-9s: nYes r
*Pay Period Begins:Wednesday
Preferred Language: English
Owner Name: Jason Gutman
Owner Email: jason@valrose.com
City, State, Zip: Hialeah, FL 33013
City, State, Zip:Hialeah, FL 33013
Fax:
Cellular Provider:
No (Client retains employee's 1-9s)
1 st Check Date: 03,111/2022
*Pay Period Ends: Tuesday
**Reports Payroll: Wednesday I *Check Day: Friday
'0
M AA:TT R 1
4 n e S o u r c e
A Vensure Employer Services Gompany
*Receives Payroll: Thursday j 'Should be a day of the week — Over time is based on 40 hours in a 7 day period
Method to Report Payroll: ✓ Email Cali In ✓ Matnx Timesheet nOther:
Method to Receive Reports Email ✓ W/Payrollther:
_.
Method to Receive Payroll Totals: ✓ Emai! El Fax1-1 Call Other:
Payroll Delivery Method: ✓ I Fed Ex I I Pick -Up I lCourier
Set Up Fee:❑Collected $ VBill on First Inv $ 150.00 _ ❑ Waived
Method of Payment (Requesting):
Secured Funds - No paper work required
Wire - No paper work required / Confirmation 1 day prior to Check date
Unsecured - Credit Check / Banking History
✓ CH - Credit Check / Banking History / Authorization to Debit Account Copy of VOIDED Check
Limployee Direct Deposit - Client must be approved Unsecured / ACH and must submit payroll to Matrix 48 hours
(2 days) prior to the check date
Notes:
Valrose Enterprises Inc., DBA Awnings By Valrose reassigning employees and payroll to Valrose
Investment group LLC
Please use EXISTING DIRECT DEPOSITS ON FILE
MOSFORM-FULLPEOENROLLMENTPACK 18 02020 MatrixOneSource
Certificate of Insurance
ISSUING A CERTIFICATE OF INSURANCE
'0
MATRI
4neSource
A Vensure Employer Services Compare
1. MatrixOneSource does NOT release a Certificate of Insurance until you pick up your first payroll from us. For
example, if you call in your payroll on Wednesday, and pick up the payroll on Friday, MatrixOneSource sends the
Certificate out on Friday, not Wednesday.
2. If you need a certificate sent out prior to picking up your first payroll, the only way we can make this happen is to
collect a non-refundable, pre -payment on your fifth scheduled payroll; we will need the pre -payment to be certified
funds. When you run your fifth scheduled payroll the pre -payment depos it will be applied, if you do not run your fifth
scheduled payroll the deposit is non-refundable.
3. Even with a pre -payment on payroll, we need 72 hours to process the request and send the Certificate out; we
also limit the initial number of Certificates to one, additional Certificates can be requested as soon as you start
running your payroll.
4. After you are in our system and running payroll, Certificates can be requested by faxing in the request form, or by
calling your payroll representative.
CANCELLATION OF YOUR CERTIFICATE OF INSURANCE
1. If you stop running payroll through MatrixOneSource, we will cancel any outstanding Certificates retroactive to the
last date that your company ran payroll through us.
2. All companies that you are working with are notified of the cancellation immediately.
3. Remember, MatrixOneSource covers your employees, NOT your company for Workers Compensation Insurance,
coverage is only in place on employees that are leased back from MatrixOneSource. If you are not running payroll,
you are not leasing your employees, as a result there is no coverage and the Certificate will be cancelled.
Client Signature:
Sales Rep Signature:
MOSFORM-FULLPEOENROLLMENTPACK 19 02020 MatrixOneSource
Retention of 1-9 Forms
'0
MATRI
&neSource
A Vensure Employer Services Gompary
All employers in the U.S. are required by federal law to verify the employment authorization and identity of each person
they hire. Employers satisfy this requirement by completing and retaining a Form 1-9 for each person they hire. The
current Form 1-9 can be obtained from our website (www.matrixonesource.com) or from the U.S. Citizenship and
Immigration Services website (http://www.uscis.gov/files/form/i-9.pdf).
Employers must retain a completed 1-9 Form for each employee for three (3) years after the date of hire or one (1) year
after the date employment is terminated, whichever is later. As a service to our clients, MatrixOneSource offers to retain
possession, on behalf of its clients, of the 1-9 Forms that its clients obtain and complete. Please indicate by checking
the appropriate line below whether or not you would like MatrixOneSource to retain the 1-9 Forms that you obtain
and complete. Note that we will destroy all 1-9 Forms after the expiration of the time that such forms are required to be
retained by law.
ONE OF THE FOLLOWING MUST BE CHECKED
1-1 The undersigned hereby requests MatrixOneSource to retain, on its behalf and for the time required by law, all
1-9 Forms that are delivered to MatrixOneSource by the undersigned.
The undersigned will retain possession of its own 1-9 Forms.
Client Name: Valrnce Investment Group LLC
Signature of Officer/Owner:
Print Name of Person Signing: -lacnn GiAnnan
Date: 03/02f2022
MOSFORM-FVLLPEOENROLLMENTPACK 20 @2020 MatrixOneSource
General Liability Insurance Policy
Certificate Request
To (Insurance Agency):
From (Client Company):
"0
MATRI
IneSource
A Vensure Employer Services Companv
Please fax a Certificate of Insurance confirming my General Liability insurance
Policy (and auto, if applicable) naming the certificate holder as:
JACKSONVILLE, FLORIDA 32256
Fax Certificate to: (904) 739-2725
MOSFORM-FULLPEOENROLLMENTPACK 21 02020 Mat ixOneSource
Request for Insurance Certificate
AMM
Client Name:
Certificate Holder Name:
Attention:
Address:
City:
State:
Zip:
Phone:
Email (this is the fastest method):
Fax:
Mail to Certificate Holder:
Waiver of Subrogation Endorsement
Other/Special Instructions:
Workers' Compensation
General Liability - If policy information is on file
Other - If policy(s) information is on file
'0
AA:TT RI
4-neSource
A Vensure Employer Services Company
MOSFORM-FULLPEOENROLLMENTPAOK 22 02020 MatrixOneSource
Workers' Comp Questionnaire
MAATR
Ii
4neSJUrce
A Vensure Empioyer Services Company
-Please explain all items answered yes in detail in the space below question*'F*
1. Do you own, operate or lease aircraft/watercraft that is used within the scope of your f
business operations?
❑Yes ZNo
2. Any present operations which involve exposure to chemicals or hazardous materials?
❑Yes RINo
3. Any work performed on barges, vessels, docks or bridges over water? I
❑Yes ZNo
4. Any work performed underground or higher than 15 feet above ground level?
❑Yes Ft/]No
5. Does employee turnover exceed 25% annually?
� ❑Yes
ENO
6. Any part time or seasonal employees?
❑Yes FPI]No
7. Any employees under 16 or over 60 years of age?
E]Yes ENO
8. Is there any volunteered or donated labor?
❑Yes ENO
_
9. Do employees travel out of state or out of country? If so, scope of travel?
❑Yes ENO
10. Is there driving exposure involved within the scope of your operations?
❑Yes ENO——
11. MVRs checked on all drivers?
❑Yes
ENO
12. Does the radius of operations of vehicles exceed 200 miles?
❑Yes ZNo
13. Any group transportation provided?
F]Yes ENO
14. Is a formal safety program in operation?
❑Yes FV]No
15. Is a drug -testing program in operation?
Yes FV
16. Is an early return/light duty program in operation?
J ❑Yes 2]No
17. Are subcontractors and/or independent contractors used?10
Yes �d No
18. Any work sublet without certificates of insurance collected?
❑Yes ENO
19. Any prior coverage declined, cancelled or non -renewed in the past three years?
E ❑Yes ZNo
20. Do you maintain a GC, CBC or other contractor's license?
I Dyes ENO
21. Are employee health plans provided?
f ❑Yes [?]No
22. Is there a labor interchange with any other business/subsidiary?
# ❑Yes
ZNo
Signature of Person Completing Form: Date: 03/02/2022
I ATTEST THAT ALL INFORMATION SUBMITTED IN THIS DISCLAIMER QUESTIONNAIRE IS TRUE AND ACCURATE.
MOSFORM-FULLPEOENROLLMENTPACK 29 @2020 MatrixOneSource
'0
Accident Report FormAT R I;
I n e S o u r c e
A Vensure Employer Services Company
POST IN A CONSPICUOUS LOCATION
REPORT ALL ACCIDENTSANJURIES IMMEDIATELY!
Call MatrixOneSource at 866-453-2722
All medical treatment beyond first aid must be preautorized by MatrixOneSource.
Client Companies must ensure that every injured employee submiys to a post accident drug screen at the
time of medical treatment. The employee's failure of refusal to submit a drug screwen could jepordize his/her
workers' compensation benefits.
1. First Aid - Get injured employee treatment by someone trained in first aid IMMEDIATELY!
2. Preauthorization and Treatment (When Employee is Not Severely Injured) - If more than first aid
is needed and the injured employee is not severely injured, notify MatrixOneSource immediately for
authorization and get the injured employee to the nearest medical clinic or facility for treatment and a
post -accident drug screen.
3. Emergency Treatment (When Employee is Severely injured) - If the injured employee is severely
injured, he/she should be taken to the nearest hospital for treatment and a post -accident drug screen
and Matrix OneSource should be notified immediately thereafter. IF YOU ARE NOT SURE IF AN
EMPLOYEE IS SEVERELY INJURED, TAKE THE EMPLOYEE TO THE NEAREST HOSPITAL FOR
EMERGENCY TREATMENT
4. Supervisor's Report of Accident - As soon as possible after the injured employee has been given
necessary medical treatment and submitted to a post -accident drug screen, his/her supervisor should
complete the Supervisor's Report of Accident form and forward it to MatrixOne Source (see information
below) within 24 hours of accident occurrence, Supervisors are responsible for obtaining statements from
any witnesses to the accident/injury and completing the Witness Report of Accident form. The form may
be obtained by calling MatrixOneSource or from the Matrix Source website at www.matrixonesource.com.
5. Employee's Report of Accident - The injured employee must complete an Employee's Report of Accident
form and forward it to MatrixOneSource (see information below) within 24 hours of accident occurrence.
If the injured employee is unable to complete the accident report due to injury, he/she should call
MatrixOneSource within the 24 hour time period (or as soon as possible) to discuss the accident.
Signature of Officer[Owner: W —
MOSFORM-FULLPEOENROLLMENT PACK
24
Dale: 0310212022
@2020 MatrixOneSource