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Contact Name
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First Name
Last Name
Email
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example@example.com
Phone number
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Organizations name:
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Organizations address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your nature of business?
What is the organizations web address?
Total W2 employee headcount:
Total 1099 employee headcount:
Desired effective date:
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Month
-
Day
Year
Date
Type of organization: (501c3, LLC, S Corp, Inc., etc.)
What is your payroll frenquency?
Monthly (12)
Semi-monthly (24)
Bi-weekly (26)
Weekly (52)
Who is your payroll provider or system?
How can we help?
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Who should we copy on any further communication with your organization?
Full Name
Title
Contact Number
Email
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2
What benefits are you interested in providing?
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Medical
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401K
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Critical Illness/ Accident
Online Enrollment Solutions
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