SSN: Employee’s social security number. Example: 123456789 Name: First, middle and last name of employee. Example: Peter J. Burke Street: Full mailing address of employee, include the PO Box. Example: 14 Maple Lane City: City/town of mailing address. Example: Anywhere State: State where employee resides (this field is prefilled, but can be changed). Example: RI Zip: Zip code. Example: 98765 Start Date: The first day of employment or reinstatement. Choose the year, month and day.
Medical Insurance: Enter 'Yes' if the employer offers health insurance and employee is eligible for this insurance. Note: Even if the employee does not currently participate in the employer-offered insurance program, the answer to this question should be 'Yes' as long as there is an option for them to participate. Date Medical Coverage Available: If the previous question was answered with a 'Yes', enter the date the employee is eligible to receive medical coverage. Choose the year, month and day.
FEIN Code: Identification number provided to the employer by Federal government, used to identify your company. Example: 123451234 Name: Full name of the company. Example: XYZ Company Address: Full mailing address of employment, include the PO Box, if necessary. The address which is used should be the payroll location. Example: 19 Cain Ave. City: City/town where payroll office is located. Example: Anywhere State: State where payroll location is located. Example: RI Zip: Zip code of payroll office. Example: 12345 or 123456789
