TECHNOLOGY ONBOARDING FORM
Company Name
Tax ID
Situs State
Full Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Signing Officer for Aflac Master Applications Contact
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
Date
Open Enrollment Start Date
-
Month
-
Day
Year
Date
Open Enrollment End Date
-
Month
-
Day
Year
Date
1st Payroll date of the year
-
Month
-
Day
Year
Date
2nd Payroll date of the year
-
Month
-
Day
Year
Date
New hire eligibility (1st of the month following ____ days)
Requesters email
example@example.com
Agent/Broker
First Name
Last Name
Save
Submit
Should be Empty: