Asure Vestwell State Integration Request Form

Asure Vestwell State Integration Request Form
Client Information
Company Name*
Client Contact Name*
Client Phone*
Please enter a valid phone number.
Client Contact Email*
example@example.com
State Information
State Program*
Have to registered with the state site?*

YesNoNot Sure
Important Notice: To enroll in this service, the plan funding must be "ACH Pull Funding". Please confirm that you have elected this option with your state plan.*

Yes, I have authorized Vestwell to auto pull the funds from our company bank account.No, I have not authorized. I understand that I must first authorize this prior to Asure submitting plan information.
Any additional Information or notes that we should be aware of?
**Important: Please continue to make timely submissions and contributions to your state provider until you recieve confirmation from Asure that your integration has been approved.**

***Asure does not provide the transfer of funds for your plan. This process is managed between the client and the state provider.

Client Information