Compliance - Employer

Employer Name *

Address

Address 2

City

State

Zip Code

Employer Tax ID

Phone Number

Ext

Secondary Phone Number

Ext

Employer Contact Person *

Contact Email *

Total # of Employees

Total # of Full Time Employees

Employer Status

Payment Method

Notes

Fiscal Year End Date

Corporation Type or Entity Type

State in which Business was first chartered

What is the Nature of this Employer’s Business?

Is the employer a Member of a Controlled Group or a Group of Affiliated Companies?

"Please add information about the employer's benefit program in the spaces below."

List Any Excluded Classes (Temporary, Seasonal, Part Time, etc.)

Benefits are offered to:

Are benefits offered to Domestic Partners

Would you like to add another Plan Type?

Check here if billing info is the same as “Employer Information” tab.

Primary Billing Name *

Secondary Billing Name

Billing Address

Billing Address 2

Billing City

Billing State

Billing Zip Code

Office Phone

Ext

Billing Contact Email *

You must use your email address for your user name

User Name *

Password * Generate Random Password

Confirm Password *

New Employer Setup Complete!

Click “Finish” to save.