Employee Addition Form

Please fill out the form below and click the submit button.

Employer Name

Employee First Name

Employee Middle Name

Employee Last Name

Employee SS#

Is this employee a Key or Highly Compensated Employee

Yes No

Date of Birth

Employee Gender

Male Female

Employee Hire Date

Employee Mailing Address

State

City

ZIP

Employee Phone Number

Employee Email Address

Plans To Add:

Medical FSA

Medical FSA Effective Date

Order Spousal FSA Card: Please indicate if a Spousal FSA Card is requested

Yes No

Dependent Care FSA

Dependent Care FSA Effective Date

HRA Plan Tier/Amount

HRA Plan Effective Date

Medical FSA

Monthly Contribution

Dependent Care FSA

Monthly Contribution

Medical Plans To Add: If we Handle your COBRA Please Mark all coverage that apply

Medical Coverage Tier

Dental Coverage Tier

Vision Coverage Tier

Medical Coverage Effective Date

Dental Coverage Effective Date

Vision Coverage Effective Date

Dependent Information: Please Input Dependent Information Below

Spouse Name

Spouse Date of Birth

Spouse SS#

Child 1 Name

Child 1 Date of Birth

Child 1 SS#

Child 2 Name

Child 2 Date of Birth

Child 2 SS#

Child 3 Name

Child 3 Date of Birth

Child 3 SS#

Child 4 Name

Child 4 Date of Birth

Child 4 SS#

Child 5 Name

Child 5 Date of Birth

Child 5 SS#

Employer Contact Information: Please Input the Name and Contact Information of Person Completing Form

Form Completed By

Contact Email Address

Date Form Completed