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Date Submitted
 Company
Contact Name
 Email
Title
 Address
Phone
 City
Fax
 State
Zip
How You Found Us
 If you found us by someo ther source not listed
to the left, please specify below
Number of Employees
 Monthly Gross Payroll
Full-Time Part-Time:
$
Combined Employer Rates UI, WFD,HCS & DI
Monthly Payroll Processing Cost
% (UC-27 FORM)
$
Name of Health Carrier Deductible for Health Insurance
$
Max Out-of-Pocket
$per month
   Total Fam Emp/Spse Parent/Child Single
# in Health Plan:
Monthly Premiums:
Emp Contributions:
# in Dental Plan:
# in Dental Plan:
# in Dental Plan:
Monthly Premiums:
Emp Contributions:
Pre-Tax Sec. 125 Plan? Yes No
Flex Spending & Dep Care Plan? Yes No
Vision Plan? Yes No
Pension Plan? Yes No
Group Life? Yes No
Group LTD? Yes No


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