EHP Intake Form
Client Information
Company Name
*
DBA if applicable
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Company Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different than physical address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State of Incorporation
*
Please Select
Alabama: AL
Alaska: AK
Arizona: AZ
Arkansas: AR
California: CA
Colorado: CO
Connecticut: CT
Delaware: DE
Florida: FL
Georgia: GA
Hawaii: HI
Idaho: ID
Illinois: IL
Indiana: IN
Iowa: IA
Kansas: KS
Kentucky: KY
Louisiana: LA
Maine: ME
Maryland: MD
Massachusetts: MA
Michigan: MI
Minnesota: MN
Mississippi: MS
Missouri: MO
Montana: MT
Nebraska: NE
Nevada: NV
New Hampshire: NH
New Jersey: NJ
New Mexico: NM
New York: NY
North Carolina: NC
North Dakota: ND
Ohio: OH
Oklahoma: OK
Oregon: OR
Pennsylvania: PA
Rhode Island: RI
South Carolina: SC
South Dakota: SD
Tennessee: TN
Texas: TX
Utah: UT
Vermont: VT
Virginia: VA
Washington: WA
West Virginia: WV
Wisconsin: WI
Wyoming: WY
Federal EIN #
*
Company Start Date
*
-
Month
-
Day
Year
Date
Business Entity Type
*
Please Select
S Corp - Elected C Corp Taxation (Form 8832)
S Corp - Business is taxed as a S Corp
LLC - Business is taxed as a S Corp, Partnership or Sole Proprietor
LLC - Elected C Corp Taxation (Form 8832)
LLP - Limited Liability Partnership
Partnership
Sole Proprietor
Non-Profit Organization
Educational Organization
Government Agency
Church or Religious Affiliate
Other
SIC Code
*
Owners & Ownership Percentage
Fiscal Year End
*
-
Month
-
Day
Year
Date
Number of Employees
*
Contacts
Main POC
*
First Name
Last Name
Main POC Email
*
Main POC Title
*
Payroll Contact
First Name
Last Name
Payroll Email
Invoice Contact
*
First Name
Last Name
Invoice Email
*
example@example.com
Payroll Information
Anticipated Enrollment Date
*
-
Month
-
Day
Year
Date
First Pay Period Date after Effective Date
*
-
Month
-
Day
Year
Date
Payroll System
*
Deduction Frequency
*
Please Select
Weekly - 52
Bi-Weekly - 26
Semi-Monthly - 24
Monthly - 12
Plan Eligibility
Minimum Age Requirement
*
Please Select
None
18
21
Other
Minimum Service Requirement
*
Please Select
None
30 days
60 days
90 days
Other
New Hire Waiting Period
30 Days
60 Days
90 Days
Are there any questions or concerns you might have that haven't been addressed yet? We're here to ensure you have all the information you need. (Optional)
Submit
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