Encrypted SSN Collection

Secure: SSN/ITIN Submission Form

All new workers must have a Social Security Number or ITIN uploaded.
Name
Legal First Name
Legal Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Month when benefits should begin (typically the month following someone's hire or eligibility start)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State of Residence
Email
example@example.com
Legal Gender / género legal
Workplace
Record ID
SSN/ITIN
Workplaces offering disability and/or life insurance must report estimated annual wages. Does this person get paid a salary or an hourly rate?
Annual Salary
Hours worked per week
Hourly Rate
Are you filling out this form for yourself or as an HR/admin representative on behalf of a worker?

I'm filling this form out on behalf of someone else as an HR/admin representative. (Please put your name in the space below)
Term and Conditions

By submitting this form, you consent to the collection and processing of personal information, including Social Security Numbers (SSNs) and Individual Taxpayer Identification Numbers (ITINs), by the United States Federation for Worker Cooperatives (“USFWC”), a California Nonprofit Mutual Benefit Corporation, for health plan enrollment purposes.

Your information will be encrypted and accessible only to essential USFWC staff involved in the enrollment process. We will never sell your information. Data will only be shared with the necessary health insurance brokers and companies for the selected plan(s).
Signature
Should be Empty:

Secure: SSN/ITIN Submission Form

Term and Conditions