Employee First Name Employee Middle Name Employee Last Name Employee SSN Employee Address 1 Employee Address 2 Employee Address 3 Employee City Employee State Employee Zip Code Employee Date of Birth Employee Date of Hire Employee State of Hire Employee Independent Contractor (IC) Dependent Health Insurance Available Date Employee Qualifies for Family Health Insurance Employer FEIN Employer Name Employer Street Address (Line 1) Employer Street Address (Line 2) Employer Street Address (Line 3) Employer City Employer State Employer Zip Code Employer Contact Name Phone Number of Contact Person