EMPLOYEE NAVIGATOR ONBOARDING FORM
Company Name
*
Tax ID
*
Number of Employees
*
Situs State
*
Desired Company ID - (unique for each client - company email works great!)
Full Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorizing signing officer
*
HR Contact
*
Billing Contact
*
Payroll frequency (# of insurance deductions throughout the year)
*
Please Select
Monthly 12
Semi-Monthly 24
Bi-Weekly 26
Bi-Weekly 24
Weekly 52
Weekly 48
Effective Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Open Enrollment Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Open Enrollment End Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1st Payroll date of the year
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
2nd Payroll date of the year
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
New hire eligibility (1st of the month following ____ days)
*
Benefits Booklet, Plan Summaries, Plan Cost and Company Contribution
Browse Files
Drag and drop files here
Choose a file
Cancel
of
CLICK TO DOWNLOAD CENSUS TEMPLATE
Attached employee and dependent census
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Requesters email
*
example@example.com
Agent/Broker
First Name
Last Name
Agent/Broker Splits
Notes
Save
Submit
Should be Empty: