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1. Executive Contact
Full Name
Role / Title
Company Name
Work Email
Direct Phone
2. Organization Structure
Full-Time Benefit Eligible Employees
Est. Average Annual W-2 Salary
Used to calculate participation viability.
Current Payroll Provider
Tax Filing Status
C-Corporation
S-Corporation
LLC
Sole Proprietorship
Non-Profit (501c3)
Current Benefits
Offers Medical Benefits?
Yes, we offer a Group Health Plan
No, we do not offer insurance
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