Preventative Care Management Program

Preventative Care Management Program
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Legal Business Name*
Date of Incorporation

MonthDayYear
Date
Employer Entity Type:*

C CorpS 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)LLPPartnershipSole ProprietorshipNot-For-ProfitGovernment AgencyChurch or Religious AffiliateOther
Employer's State of Organization*
Contact Person (If Different)
Employer Fiscal Year End*

Calendar YearOther
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business EIN / Tax ID#*
How many W2 employees do you currently have?*
How often are your employees paid?*

12 - Monthly24 - Semi-Monthly26 - Bi-Weekly52 - Weekly
Do you currently have a section 125 cafeteria plan implemented in your company?*

YesNo
Do you have any affiliated companies that you own?*

YesNo
Please describe your trade or business.
Do you use a third-party payroll processor?*

YesNo
Who is your Payroll Provider?*
What's the percentage of employee turnover per year?
Do you pay a portion of your employees health benefits?*

YesNo

Who are all the owners of the company (please list names and percentages of ownership)?*

Please provide Company Officers Names and Titles.*

Please provide the benefits sponsored by the Employer. (Select ALL that apply)

WellnessMedicalDentalVisionCancerCritical IllnessHospital IndemnityLifeAccidentShort-Term DisabilityLong-Term DisabilityI.R.C. Code Section 125 PlanFlexible Spending AccountDependent CareHRAHSAOther
Do you have any of the following Employees?

UnionPart-TimeOther
What is the best way(s) to contact you?

PhoneEmailText Message
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