Installation Request Form 

Company Name
Address City Zip
Type of Business State  
HR Contact Ph: 
E-mail: Fax:
Benefit Contact Ph: 
E-mail: Fax:

Number of Locations 

Number of State(s)

Number of Full-time Employees

   E-mail address for billing:

Number of Part-time Employees
Services    
Payment Method: Check:                                Deposit Amount: $  

Servicing Representative: e-mail or phone:

The above client understands that AdminExcel and the client agree to not disclose the confidential information and trade
secrets of each others respective company without written consent. AdminExcel and Employer has a continuing duty
not to disclose the Proprietary Confidential Information of employer or AdminExcel trade secrete. regardless of whether
or not it is feasible to proceed regarding other aspects of any relationship. This interim agreement is subject to our
standard service agreement.

Enter any additional comments in the space provided below: