Employer Name is a required field.
Employer Phone Number is a required field.
Employer Contact Name is a required field.
Employer Email Address is a required field.
Employee Name is a required field.
Employee SSN is a required field.
You must indicate if employee was covered by your group insurance plan.
You must indicate if employees dependents were covered by group health insurance plan.
You must indicate if employee enrolled in a COBRA Plan upon terminating employment.
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