New Hire/Newly Eligible Submission Form
Please complete the information below to have your new hire activated in the ICHRA platform and receive communications regarding ICHRA, including how to enroll. For more information, go to the Mi-Benefits Admin HUB. If you need any assistance, please send us an Assistance Request Form (ARF) through the Admin HUB. Thank you!
Name of Administrator Submitting a New Hire
*
Administrator Email
*
example@example.com
Company Name
*
Employee
Details:
Employee ID
optional
Employee Full Name
*
First Name
Last Name
Hire Date
*
/
Month
/
Day
Year
Add the hire date for calculations of effective date.
Company E-mail
*
If you do not have company issued email address please assure the email on file is up to date and in use by the employee.
Personal Email
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Phone Number
*
Date Of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Please Select
Male
Female
Class
*
Please Select
Single Class (all employees)
By State
Unique (example: Location Code)
Use the Class Type as defined in your Allowance Model
Type in your company's unique class for this employee if needed
optional
Employment Type
*
Please Select
Part-time
Full-time
Wage Type
*
Please Select
HOURLY
SALARY
Yearly Salary
*
For hourly employees, multiply the hourly rate by 130 hours, then multipy by 12 to get the estimated yearly total
Submit New Hire
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