Employee Benefits Intake Form

Legal business name *

DBA (if applicable) *

Tax ID (EIN) *

Entity type (Corporation, Partnership, LLC, Sole Proprietor, Nonprofit, etc.) *

Year business was established *

Industry / nature of business *

Owner(s) Names *

Primary business address *

Mailing address (if different)

/ date Contact

Additional office locations (if applicable)

Contact person's name *

Contact person title *

Contact person's phone number *

Contact person's Email *

Total number of employees working 20-30+ hours in each tier:

Overall Total # Of Employees

Single (employee only)

Employee + Spouse

Employee + Child(ren)

Family

Current carrier

Current plan(s) offered (attach summary/recent invoice if possible)

Renewal date / effective date

Employer contribution strategy (flat dollar or % for each tier)

Participation percentage (how many are enrolled out of eligible)

Any HRAs, HSAs, or other funding arrangements in place?

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