ONBOARDING FORM
Company Name
Tax ID
Situs State
Number of Employees
Full Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Signing Officer for Aflac
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)
Requesters email
example@example.com
Agent/Broker
First Name
Last Name
Document Upload
Please add any benefits documents, plan summaries and rates/contributions. Feel free to leave this blank if it doesn't apply.
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