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Step 1 of 4 - Company

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Company Information
Business Name*
Contact*
Title*
Phone*
Email*

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Details
Primary Address*
Zip*
# Full-time Employees*
# Part-time Employees*
Federal ID # (If Known)
Business Description
Tell us about your company's products, services and employees' job functions.

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Benefits
Are you interested in providing benefits to your employees through Emplicity?
- Yes
- No
Click 'Next' to continue.
Benefit Type
Select Desired Benefits Below:
- Medical
- Dental
- Vision
- Life
- LTD
- STD
- 401k
- Supplemental
- Not Sure
Please complete the fields below:
Medical
Renewal Month
Insurance Company or Provider Network
Employer Contribution ($ or %)
Employee
Dependent
Attach most recent master payroll register:
Drop files here or

Max. file size: 30 MB.
Dental
Renewal Month
Insurance Company or Provider Network
Employer Contribution ($ or %)
Employee
Dependent
Vision
Renewal Month
Insurance Company or Provider Network
Employer Contribution ($ or %)
Employee
Dependent
Life
Renewal Month
Insurance Company or Provider Network
Employer Contribution
Employee
Long-Term Disability
Renewal Month
Insurance Company or Provider Network
Employer Contribution
Employee
Short-Term Disability
Insurance Company or Provider Network
Employer Contribution
Employee
401k
Insurance Company or Provider Network
Employer Contribution
Supplemental
Insurance Company or Provider Network
Employer Contribution
Employee
Dependent
Number of benefit eligible employees
(50% of eligible employees must be enrolled in the benefit plan, excluding union, part-time, temporary/seasonal, COBRA participants, employees in the waiting period and employees enrolled through another group policy.)
Number of enrolled employees
Number of COBRA participants
(COBRA participation may not exceed 10% of enrolled employees.)
To your knowledge has any employee, dependent or person to be covered had claims over $10,000 in the past 12 months?
- Yes
- No
To your knowledge is any employee, dependent or person to be covered unable to work for an extended period of time due to an injury or illness?
- Yes
- No
To your knowledge are there any current pregnancies or hospitalizations in the past 12 months for any employee, dependent of an employee or person covered?
- Yes
- No
To your knowledge is any employee, dependent or person to be covered ever had, consulted for, had treatment rendered, been advised to have treatment or received treatment, or been hospitalized for any of the following conditions:
- Cardiovascular disease or heart attack?
- Yes
- No
- Disorder of the kidney?
- Yes
- No
- Chronic disorder of the stomach, intestine or liver?
- Yes
- No
- Mental or nervous condition; central nervous disorders?
- Yes
- No
- Diabetes, respiratory disorders; cancer; brain tumor; blood disorders or transplant?
- Yes
- No
To your knowledge has any employee, dependent or person to be covered ever been diagnosed as having AIDS or aids-related complex (ARC) by a medical professional?
- Yes
- No
For each Yes answer, please provide the following information (Provide additional information in an attached document if necessary.)
Condition (Diagnosis)
Age
Date Diagnosed
Prognosis
Date of Services
Total Chargers (Est.)
Attach additional documents here, if needed:
Drop files here or

Max. file size: 30 MB.
By continuing, I declare that the above answers and statements are true and correct to the best of my knowledge.

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Workers' Compensation
Are you interested in Workers' Comp?
- Yes
- No
Do you have more than 5 Workers' Comp Classifications?
- Yes
- No
Click 'Next' to continue.
Please upload a file with each workers' compensation class code listed individually -- if you do not currently have workers' compensation insurance, please complete the number of employees under each job description as well as their combined yearly remuneration. If you currently have a workers' compensation policy, please also list your current rates for each class code.

Please include:
State
Code (If known)
Class Code Description
Effective Rate Per $100 of Payroll (If known)
# Full-time Employees (Over 30 hrs/week)
# Part-time (Under 30 hrs/week)
Estimated Annual Payroll
File
Drop files here or

Max. file size: 30 MB.
Please list each workers' compensation class code individually below--if you do not currently have workers' compensation insurance, please complete the number of employees under each job description as well as their combined yearly remuneration. If you currently have a workers' compensation policy, please also list your current rates for each class code.
Workers' Comp Classification #1
State
CODE (If Known)
Effective Rate
Workers' Comp Class Code Description (If Known)
#Full-time
Over 30 hrs/week
#Part-time
Under 30 hrs/week
Estimated Annual Payroll
Workers' Comp Classification #2
State
CODE (If Known)
Effective Rate
Workers' Comp Class Code Description (If Known)
#Full-time
Over 30 hrs/week
#Part-time
Under 30 hrs/week
Estimated Annual Payroll
Workers' Comp Classification #3
State
CODE (If Known)
Effective Rate
Workers' Comp Class Code Description (If Known)
#Full-time
Over 30 hrs/week
#Part-time
Under 30 hrs/week
Estimated Annual Payroll
Workers' Comp Classification #4
State
CODE (If Known)
Effective Rate
Workers' Comp Class Code Description (If Known)
#Full-time
Over 30 hrs/week
#Part-time
Under 30 hrs/week
Estimated Annual Payroll
Workers' Comp Classification #5
State
CODE (If Known)
Effective Rate
Workers' Comp Class Code Description (If Known)
#Full-time
Over 30 hrs/week
#Part-time
Under 30 hrs/week
Estimated Annual Payroll
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Email
This field is for validation purposes and should be left unchanged.

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