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Employer Onboarding Form
Thank you for the opportunity. We truly value your business and look forward to working with you! Please complete the following information.
If you have any questions, please contact us at 708-535-3006 or
Contact Us
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We will not share your information with any third party.
Privacy Policy
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Employer Information
Company Name
Admin Contact Name
Title
Phone
Email
Tax ID Number
Street Address
City
State
Please select
AL
AK
AZ
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WV
WI
WY
Zip Code
County
Requested Start Date
Employee Eligibility
Domestic Partnership Coverage
Please select
Yes
No
Retiree Coverage
Please select
Yes
No
New Hire Waiting Period
Please select
Date of Employment
1st of the month following employment start date
1st of the month after 30 days
1st of the month after 60 days
90 days (max)
Waive Initial Waiting Period (New Groups)
Please select
Yes
No
Termination Date for Employees
Please select
Date Terminated
End of Month (Most Common)
Owners/Partners
Number of Partners or Owners
Owner Verification: List each owner by First and Last Name
Number of Full-Time Eligible Employees
Number of Part-Time Employees
Employer Contributions Percentages
Employee Only Coverage
Please select
0%
25%
50%
75%
100%
Flat Amount (TBD)
Unknown
Employee and Spouse (Spousal Portion of Premiums)
Please select
No Spousal Coverage Offered
0%
10%
25%
50%
75%
100%
Flat Amount (TBD)
Unknown
Employee and Child(ren) (Child(ren) Portion of Premiums)
Please select
No Child(ren) Coverage Available
0%
10%
25%
50%
75%
100%
Flat Amount (TBD)
Unknown
Employee and Family (Family Portion of Premiums)
Please select
No Family Coverage Available
0%
10%
25%
50%
75%
100%
Flat Amount (TBD)
Unknown
Current Insurance and Payroll Company Information
Payroll Company
Payroll Cycles
Please select
52 - Pay
26 - Pay
24 - Pay
12 - Pay
Benefits Administration Systems
Please select
BSwift
EASE
Employee Navigator
Gusto
Payroll Company
Other
None
Medical Insurance Company (or NA)
Dental Insurance Company (or NA)
Vision Insurance Company (or NA)
Group Life Insurance Company (or NA)
Short/Long Term Disability Insurance Company (or NA)
Keyperson / Buy-Sell Life Insurance Company (or NA)
Compliance
125 Doc/Cafeteria Plan Updated Current Year
Please select
Yes
No
Unknown
ERISA Wrap Document Updated Current Year
Please select
Yes
No
Unknown
COBRA / State Continuation Administration Company
Please select
Third Party Administration Company (TPA)
Payroll Company
In-House (HR/Employer)
Unknown/None
Number of Employees on COBRA / State Continuation
Employee Handbook Last Updated (MM/DD/YY) or N/A
Sexual Harassment Training Renewal Date (MM/DD/YY) or N/A
Additional Information
Active Employee Wellness Program
Please select
Yes
No
Workers Compensation Renewal Date (MM/DD/YY)
Workers Compensation Insurance Company
Commercial Insurance Renewal Date (MM/DD/YY)
Commercial Insurance Company
Any Additional Information to Provide:
Submit Form
Thank you for completing the Employer Onboarding Form. Someone from our enrollment service team will be in touch.
If you need immediate attention please call 708-535-3006 or
Contact
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