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Required Employee/independent contractor Information |
Required Employer Information |
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Employee/Independent Contractor's full name |
Employer's name (please use corporate name) |
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(Please identify first, middle, and last name) |
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Employee/Independent Contractor's address |
Employer's address (please provide address where Income Withholding Orders should be sent.) |
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Employee/Independent Contractor's Social Security Number/Individual Taxpayer Identification Number |
Employer's Federal Employer Identification Number (FEIN). If you have more than one FEIN, please make certain you use the same FEIN you use to report your quarterly wage information when reporting new hires. |
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Employee/Independent Contractor's date of hire |
Reemployment assistance identification number (if applicable) |
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Employee/Independent Contractor's state of hire (only if reporting as a multistate employer) |
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Optional employee/independent contractor Information |
Optional Employer Information |
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Employee/Independent Contractor's date of birth |
Employer's phone number |
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Employee/Independent Contractor's state of hire |
Employer's fax number |
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Employer's email address |
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Employer’s contact (individual’s name) |
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Medical insurance availability |