Legal Business Name
*
How many full-time W2 employees (working over 30 hours or more per week) do you currently have?
*
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Date of Incorporation
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Employer entity type:
*
Please Select
C Corp
S Corp (Taxed as S Corp- passthru, partnership, or sole proprietor)
S Corp (Taxed as C Corp)
LLC (Taxed as S Corp-passthru, partnership or sole proprietor)
LLC (Taxed as C Corp)
LLP
Partnership
Sole Proprietorship
Not- For- Profit
Government Agency
Church or Religious Affiliate
Other
Employer's State of Organization
*
Contact Person (If Different)
Employer fiscal year end:
Calendar Year
Other
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business EIN/Tax ID#
*
No spaces required
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How often are you employees paid?
*
Please Select
12 Monthly
24 Semi-monthly
26 Bi-weekly
52 Weekly
Do you currently have a section 125 cafeteria plan implemented in your company?
Yes
No
Do you have affiliated companies that you own?
*
Yes
No
Please describe your trade of business:
Do you have a third party payroll provider?
*
Yes
No
Who is your Payroll Provider ?
*
Do you work with a PEO?
*
Yes
No
What's the percentage of employee turnover per year?
Do you pay a portion of your employees health benefits?
*
Yes
No
Who are all of the owners of the company (please list names and percentages of ownership)?
*
Rows
Owner's Name
Percentage
Owner #1
Owner #2
Owner #3
Owner #4
Do you offer your employees major medical coverage?
*
Yes
No
Please provide company officers names and titles
*
Rows
Officers Name
Title
Officer #1
Officer #2
Officer #3
Officer #4
Please provide the benefits sponsored by the Employer. (Select ALL that apply)
*
Rows
Select ALL that apply
Wellness
Medical
Dental
Vision
Cancer
Critical Illness
Hospital Indemnity
LIfe
Accident
Short-Term Disability
Long-Term Disability
I.R.C. Code Section 125 Plan
Flexible Spending Account
Dependent Care
HRA
HSA
401(k)/457 Plans
403(b) Plans
Defined Benifit Plans
ESOP Plans
Cash Balance Plans
Do you have any of the following Employees? (Select ALL that apply)
*
Full-Time
Part-Time
Union
Other
What is the best way(s) to contact you?
*
Please Select
Phone
Email
Text Message
All of the above
Submit
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