AFLAC GROUP & TECHNOLOGY REQUEST FORM
COMPANY INFO
COMPANY NAME
NUMBER OF W2 EMPLOYEES RAN THROUGHOUT THE YEAR
EFFECTIVE DATE
-
Month
-
Day
Year
Date
COMPANY ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CURRENT PLATFORM OR PAYROLL SYSTEMS BEING USED
BROKER/CONSULTANT
REQUESTER INFO
REQUESTERS NAME
First Name
Last Name
REQUESTERS EMAIL
example@example.com
REQUESTERS PHONE
Please enter a valid phone number.
MESSAGE
ANY ADDITIONAL DOCUMENTS
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