Preventative Care Management Program
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Legal Business Name
*
Date of Incorporation
-
Month
-
Day
Year
Date
Employer Entity Type:
*
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#
*
How many W2 employees do you currently have?
*
How often are your employees paid?
*
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 any affiliated companies that you own?
*
Yes
No
Please describe your trade or business.
Do you use a third-party payroll processor?
*
Yes
No
Who is your Payroll Provider?
*
What's the percentage of employee turnover per year?
Do you pay a portion of your employees health benefits?
*
Yes
No
Who are all the owners of the company (please list names and percentages of ownership)?
*
Rows
Owner Name
Percentage
Owner #1
Owner #2
Owner #3
Owner #4
Owner #5
Owner #6
Owner #7
Owner #8
Do you offer your employees major medical coverage?
*
Yes
No
Please provide Company Officers Names and Titles.
*
Rows
Officer Name
Title
Officer #1
Officer #2
Officer #3
Officer #4
Officer #5
Officer #6
Officer #7
Officer #8
Please provide the benefits sponsored by the Employer. (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
Other
Do you have any of the following Employees?
Union
Part-Time
Other
What is the best way(s) to contact you?
Phone
Email
Text Message
Submit
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