Benefits Enrollment Request Form

1
Company Name* This field is required.
2
Primary Contact Name* This field is required.
First Name
Last Name
3
Primary Contact Email* This field is required.
example@example.com
4
Company AddressIf you are already our client, you can skip this info, we have these details on file.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Primary State of Operation* This field is required.
Please Select
Please Select
Select a state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other / Outside U.S.
6
Industry
Please Select
Please Select
Select an industry
Professional Services
Technology / Software
Healthcare
Manufacturing
Retail / Ecommerce
Hospitality / Food Service
Construction / Trades
Education / Nonprofit
Financial Services
Fitness Studios
Lounge or Club
Other
7
Approximate Number of Employees* This field is required.
8
Current Benefits Status* This field is required.
We do not currently offer formal benefits and want to set them up
We have some benefits in place and want to add or update options
We want a full review of our current benefits program
Other
9
Which benefits would you like to discuss or enroll in for your team?* This field is required.
Retirement plan (e.g., 401(k) or similar)
Health / Medical insurance
Dental insurance
Vision insurance
Paid Time Off (PTO) policy
Vacation policy
Other voluntary benefits (e.g., life, disability, ancillary)
10
Company Discounts
Health insurance discounts
Gym membership discounts
Transportation subsidies
Childcare support
11
If you selected a retirement plan, please share any relevant details (for example: existing provider, whether this is a new plan or a change, approximate eligibility rules, or any goals you have for the plan).
12
If you selected health, dental, vision, or other voluntary benefits, please share any relevant details (for example: current carrier, renewal date, desired coverage levels, or budget considerations).
13
If you selected PTO or vacation, please describe your current or desired policy structure (for example: accrual vs. lump-sum, eligibility, carryover rules, or any changes you are considering).
14
Desired Effective Date for New or Updated Benefits
Date
Month
Day
Year
15
How soon would you like to move forward?
As soon as possible
Within the next 30 days
Within the next 60–90 days
On or before our next renewal date
Exploratory only at this time
Other
16
Are there any specific priorities or concerns we should focus on?
Compliance with applicable laws and state mandates
Cost control and budget management
Employee attraction and retention
Simplifying administration
Improving employee understanding of benefits
Other
17
Additional Details or Questions
Should be Empty: