New Hire/Newly Eligible Submission Form

New Hire/Newly Eligible Submission Form

Please complete the information below to have your new hire activated in the ICHRA platform and receive communications regarding ICHRA, including how to enroll. For more information, go to the Mi-Benefits Admin HUB. If you need any assistance, please send us an Assistance Request Form (ARF) through the Admin HUB. Thank you!
Name of Administrator Submitting a New Hire*
Administrator Email*
example@example.com
Company Name*
Company EID*
Employee Details:
Employee Full Name*

First NameLast Name
Hire Date*

MonthDayYear
Add the hire date for calculations of effective date.
Location Code
Company E-mail*
If you do not have company issued email address please assure the email on file is up to date and in use by the employee.
Personal Email
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select State*
Phone Number*
Date Of Birth*

MonthDayYear
Date
Gender Assigned at Birth*
Employee Social Security Number*
Employment Type*
Wage Type*
Yearly Salary*
For hourly employees, multiply the hourly rate by 130 hours, then multipy by 12 to get the estimated yearly total
Should be Empty: