BOIR Form
Fill out the form carefully for BOIR registration
Company Name
EIN Number
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Registered Agent Email
example@example.com
Registered Agent Name
First Name
Last Name
Owner #1
First Name
Last Name
Owner #2
First Name
Last Name
Owner #3
First Name
Last Name
Owner #4
First Name
Last Name
Photo ID
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I agree to have my company’s BOIR Filing completed by Employer Benefits Consulting staff at a fee of $260, and attest that the company information below is valid and up to date.
First Name
Last Name
Date
*
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Month
-
Day
Year
Date
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