Company Name  * EIN  * Address  * City  * State  * Zip  * Contact Name  * Phone Number  * Email Address Fax Principal Office Location (State)  * Start Date  * End Date  * Effective Date  * Organization Type CorporationS CorporationLimited Liability CompanyProfessional CorporationPartnershipGovernment EntityNon-Profit Organization Class of Eligible Employee Same as Group Health PlanAll EmployeesSalaried EmployeesHourly Employees Service Period Requirements 90 Days after hire60 Days after hire30 Days after hireDate of HireOther Entry Date Date Requirements are metFirst pay period following requirementsFirst day of the month following requirements Benefits Coordinator  * Core Health Insurance Company Name Non-Core Health Insurance Benefits Group Term Life Insurance Disability Insurance Dental Insurance Cancer Insurance Vision Insurance AD&D Insurance Prescription Drug Coverage Other Insurance Coverage Group Term Life Insurance Company Name Is the employer subject to FMLA Yes No Is an HSA provided by the employer Yes No   Notes Agent Name Agent Phone Number Quoted Annual Fee Quoted Monthly Fee Security code:   * Do not enter anything in this field:

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