Payment Form
For ESAC-Accredited Professional Employer Organization (PEO) ONLY

ONLY PEO entities which utilize Employers Services Assurance Corporation (ESAC) to submit filings and other documents to the Department should utilize this form for payment of registration and renewal fees. Entities which do not utilize ESAC for filing submissions must use the PEO Application/Renewal form for registration and renewal applications and payment of fees.


TYPE OF REGISTRATION:
PLEASE NOTE THAT ALL PEO REGISTRATION AND RENEWAL FEES SUBMITTED ARE NONREFUNDABLE
    


     

SECTION ONE:
1.a. General Individual Registrant Information






1.b. General Group Registrant Information





Legal and DBA Names of PEOs which are part of the Group applicant:

Legal Name DBA Name
Use one line per PEO. Click to add lines for additional PEOs.

Number of PEOs in group:  

Payment for group initial application fees or renewal fees are calculated the number of PEOs in the group by the applicable fee.

1.c. Limited Individual Registrant Information






1.d. Limited Group Registrant Information





Legal and DBA Names of PEOs which are part of the Limited Group applicant:
Legal Name DBA Name
Use one line per PEO. Click to add lines for additional PEOs.

Number of PEOs in group:  

Payment for group initial application fees or renewal fees are calculated the number of PEOs in the group by the applicable fee.

Name of Person Submitting Payment: 
Title: 
Company: 
Email: 
 By checking this box, I attest and affirm that I am authorized to submit this payment on behalf of the applicant/registrant named herein, and that the information included is true, correct and complete to the best of my knowledge and belief. I understand that knowingly providing false or fraudulent information or knowingly make a material misrepresentation in connection with this payment submission may result, inter alia, in the denial of the application, revocation of registration, or imposition of fines and penalties, as set forth in the Professional Employer Organization Registration Act, K.S.A. 44-1701 et seq.

Date: 07/24/2024

When you click the submit box below you will be redirected to a page for payment of the applicable fees. Once payment is made you will receive an email confirming receipt of payment by the Department.