AmCheck Austin New Client Setup Form

Membership Information

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Are you a returning Client?

Affiliate Office(Required)

REQUESTED START DATE: (Required)

This will be the first day of access for your account.

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Client Company Primary Contact Email:(Required)

Affiliate Billing Contact Information

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Producer Contact Information

This is the main sales contact from your affiliate office

Account Manager Contact Information

This is the account manager responsible for this client, if there is one.

Producer Office Location

Client Company Information

Provide the complete company name and address

Client Company Name:(Required)

Number of Employees:(Required)

Client Company Phone(Required)

Additional Authorized Users

This client account allows for additional authorized users. These users will be able to log in and use our services through the Guardian HR online portal. You can enter these users now or at a later date through our online portal or you can email the authorized users' contact information to support@guardianhr.com.

Additional Contact 1 Title

Additional Contact 1 Email :

Additional Contact 1 Phone

Additional Contact 2 Title

Additional Contact 2 Email:

Additional Contact 2 Phone

Additional Contact 3 Title

Additional Contact 3 Email:

Additional Contact 3 Phone

Additional Contact 4 Title

Additional Contact 4 Email:

Additional Contact 4 Phone

Client Office Locations

Please enter additional client office locations. If you do not know this information, it can be collected at a later time by the HR manager assigned to this client.

# of Employees at Location

Special Instructions for Setting Up This Account

Product/service description: Premium

Recurring Amount: $195/Month

Product/service description: Plus

Recurring Amount: $95/Month

Product/service description: Hotline

Recurring Amount: $9.50/Month

AGREEMENT FOR SERVICES

BY COMPLETING THIS NEW CLIENT SETUP FORM AND RETURNING IT TO GUARDIAN HR, CLIENT HEREBY AGREES TO A MINIMUM ONE (1) YEAR TERM (“INITIAL TERM”). AT THE CONCLUSION OF THE INITIAL TERM, CLIENT AGREES TO AN AUTOMATIC RENEWAL FOR ANOTHER TERM OF THE SAME LENGTH UNLESS WRITTEN NOTICE OF CANCELLATION IS SENT TO GUARDIAN HR AT BILLING@GUARDIAN-HR.COM NO LATER THAN THIRTY (30) DAYS PRIOR TO THE RENEWAL DATE. IF CLIENT TERMINATES THIS AGREEMENT PRIOR TO THE END OF A TERM, PAYMENTS FOR ALL REMAINING MONTHS IN SAID TERM WILL BE ACCELERATED AND IMMEDIATELY DUE AND PAYABLE IN FULL.

CLIENTS MUST HAVE A VALID BANK ACCOUNT TO ENROLL AND AGREE TO ALLOW GUARDIAN HR TO BILL THE ACCOUNT FOR ALL PAYMENTS AND IN THE EVENT OF AN EARLY CANCELLATION FOR ALL REMAINING PAYMENTS DUE IN THE APPLICABLE TERM. CLIENT UNDERSTANDS THAT THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL IT IS CANCELLED IN WRITING.

Authorized Representative Name(Required)

Authorized Representative Signature:(Required)

Signature Date

Payment Authorization

SELECT FORM OF PAYMENT BELOW:(Required)

Please note, due to conflict of interest concerns, Guardian HR consultants and contracted attorneys are not permitted to communicate with employees of the client other than the designated management contacts listed on this form.

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