Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 31. Provide Decision Maker and Company InfoLayoutCompany Name * If your company has a different name than your D.B.A, please provide it here.Nature of Business * Examples: Public Sector, Home Goods, Child Care ServicesEIN/TIN *Companies' Employer Identification Number or Tax Idenfitication NumberContact Name *FirstLastName of the Decision MakerContact Title *Title of Decision MakerLayoutContact Phone *Best Phone Number for Decision MakerContact Email *Best Email for Carrier Information & BillingNext2. Provide Dates of First and Second DeductionLayoutPreferred First Deduction Date *Preferred Second Deduction Date *If applicable to your state and company position, as allowed by law, please signify if domestic partner or civil union relationships are recognized by your company? *YesNoNumber of Benefit Eligible Employees *Day of the Week Employees Get Paid *MondayTuesdayWednesdayThursdayFridaySaturdayDo you, or your family, have ownership in this business entity? *YesNoNext3. Upload your most recent Employee CensusDownload the Employee Census Template HERE File Upload * Click or drag a file to this area to upload. Your submission will be encrypted upon clicking "Submit"Submit
