Employer Intake Form

Employee Navigator Group Setup

Provide company, contact, payroll, and current benefits details so we can configure your new or renewing group in Employee Navigator. Fields marked * are required.

Key Contacts

Who should we contact and who needs system access?

Business Owner or Principal Name *

Owner Phone *

Owner Email *

Is the HR/Benefits Admin Contact Different from the Owner? *

Other People Needing Employee Navigator Login Access (include name and email for each)

Employee Class Structure

Do benefit offerings, eligibility rules, or employer contributions differ between groups of employees? *

Payroll

Current payroll provider *

Pay frequency *

Does everyone use the same pay frequency? *

Current Benefits

This section may be left blank if not applicable and/or benefits have not been previously offered.

Current medical carrier and plan name(s)

Current dental carrier

Current vision carrier

Current life / AD&D carrier

Current Short Term Disability / Long Term Disability carrier

Current retirement plan provider and type

Other voluntary / benefits currently offered

Plan renewal / effective date

Open enrollment start date

Open enrollment end date

Eligibility Rules

Minimum hours per week to be eligible for benefits *

Waiting period for new hires before coverage starts *

Do eligibility rules vary by benefit line? *

Which dependent types are eligible for coverage?

Are there any special dependent eligibility restrictions or rules? *

When an employee loses eligibility or terminates employment, when does benefit coverage end? *

If any benefits use different termination rules, please specify each separately.

Employer Contribution / Funding Structure

Are employer contributions the same for all eligible employees? *

Specify unique contributions and funding for employee types / classes

Medical Insurance Employer contribution type *

Dental plan funding *

Vision plan funding *

Basic life / AD&D funding *

Retirement Plan (401k, 403b): Minimum hours or tenure required before the employer match applies (this can differ from the general benefits eligibility threshold)

Who can contribute their own salary deferrals into their retirement account, regardless of whether they qualify for the employer match?

Match formula, for example: 50% of the first 6% deferred, or 100% up to 3%

Family Medical Leave Insurance funding *

Short Term Disability / Long Term Disability funding *

Note any other benefit lines with employer contributions not captured above (e.g., HSA seed contribution, HRA funding, voluntary benefit employer subsidy).

Additional Notes

Anything else you would like us to know before building your company's profile

Supporting documents (e.g. prior plan summaries, invoices, statements, renewals, or proposals)

Review your entries above, then submit when ready. We'll create your company profile in Employee Navigator from this information.

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