Client Onboarding
Company Legal Name
*
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Primary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Company Website
EIN
Executive Contact
First Name
Last Name
Executive Contact Email
example@example.com
Executive Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Administrative Contact Name
First Name
Last Name
Administrative Contact Email
example@example.com
Administrative Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Contact Name
First Name
Last Name
Billing Contact Email
example@example.com
Billing Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Payroll Frequency
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Coverage Effective Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Waiting Periods
1st of the month following date of hire
1st of the month following 30 days
1st of the month following 60 days
Other
Are there multiple locations?
Yes
No
Are there multiple companies to be included in coverage?
Yes
No
Number of full-time, benefit eligible employees:
Number of part-time employees:
Please upload the following information, if applicable: All current benefit summaries, most recent renewal or quote with rates, enrollment booklets, employee handbook, company logo in jpeg.
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All current benefit summaries, most recent renewal or quote with rates, enrollment booklets, employee handbook, company logo in jpeg.,
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Employee Census (Upload you own excel format, or use the template below)
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⬇️ Download the Employee Census Template
.
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Should be Empty: