CONTACT US
401.921.3514

FMLA Services Application

YOUR COMPANY INFORMATION

Company Legal Name *
Company Address: *
 
City: *
State: *
Zip: *
Phone *
Fax *
Contact Person Name *
Contact Email *
Insurance Broker Name
Insurance Broker Email Address
Insurance Broker Phone Number
Total number of employees eligible
for FMLA benefits *

FMLA PLAN DETAILS

Plan Year Method (check one) *
Calendar year
Fixed 12 Months
  If using the “Fixed 12 Months” method, please select month and day of year end:
Rolling 12 month period measured backwards (most popular method)
12 month period measured forward from date of leave
Time Tracking Increment (check one) *
Hours
Minutes

BILLING DETAILS

Billing is handled automatically via ACH from a client authorized bank account. All fees for FMLAToday administrative services will be deducted via ACH direction from your bank account.
Bank Name *
Bank Account Type * Checking       Savings
Routing Number * (what's this?)
Account Number * (what's this?)