Fillable Peo074 New Employee Packet (Paychex)

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Peo074 New Employee Packet (Paychex)

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Office/Client Number
New Employee Packet
Employer Information: Choose your option for submitting employee information. For detailed instructions for these options, refer to the
PEO New Employee Packet Employer Instructions.
❑ Option 1 - Spreadsheet Submission and Certification (Complete one spreadsheet attachment per client code)
(Requires Authorized Signature in Section A)
❑ Option 2 – NEP Submission: Complete B1 and B2
❑ Option 3 – Online payroll clients only: Print out online payroll summary information for applicable new employee in place of
completing Section B1 (Click here for sample online payroll summary.)
A - EMPLOYEE INFORMATION SUBMISSION AND CERTIFICATION
As an authorized representative, I am electing to submit all required new employee information via the approved spreadsheet or through a
printout of the online payroll summary information. I attest that I have accurately and completely provided all required information and
understand that Paychex Business Solutions (PBS) is relying on the accuracy and completeness of the information provided. I further
understand that this information will be the basis upon which PBS sets up each employee and I accept responsibility for any incorrect or
inaccurate information provided to PBS.
Client Authorized Signature _________________________________________
Signature Title Date
B1 - CORPORATE INFORMATION COMPLETED BY MANAGER OR SUPERVISOR
Client Name
Department Name or Number __________________________
Last four digits of Social Security Number _________________
Work Authorization Expiration (if applicable) ___/ ____/ _____
Employee Name __________________________________________
Employee ID _____________________________________________
Employee Worksite Location (full address required)
Address _________________________________________ City _________________________ State _________ Zip
Status ❑ Full-time ❑ Part-time
Rate of Pay 1 $ _______________
Rate of Pay 2 $ _______________
Rate of Pay 3 $ _______________
❑ per hour ❑ period (select one)
❑ per hour ❑ period (select one)
❑ per hour ❑ period (select one)
Gender ❑ Female ❑ Male Hire Date _____________________
Withholding State ___________ State Unemployment Insurance State ___________
Job Title ____________________ Workers’ Comp Class Code _________________
Union Employee ❑ Yes ❑ No
Residence State ____________
Benefit Insurance Class Code
Location Name _______ Insurance Standard Hours___
Job Category (select one)
❑ Executive/Senior Level Officials and Managers [1.1] ❑ First/Mid-Level Officials and Managers [1.2] ❑ Professionals [2]
❑Technicians [3] ❑ Sales Workers [4] ❑ Office and Clerical [5] ❑ Craft Workers (skilled) [6] ❑ Operatives (semi-skilled) [7]
❑Laborers (unskilled) [8] ❑ Service Workers [9]
Description of Duties (provide a short description of daily regular activities) _____________________________________________
❑ Work from remote office or location (note how often) _______________________________________________________________
❑Travel (note how often) _______________________________________________________________________________________
Supervisor, Manager, or
Authorized Signature _____________________________________________
Signature Title Date
B2 - EQUAL EMPLOYMENT OPPORTUNITY INFORMATION*
We are subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In
order to comply with these laws, you must complete the Job Category information. Although employees are invited to voluntarily self-identify their
race and ethnicity, submission of this information is voluntary and refusal to provide it cannot and will not subject an employee to any adverse
treatment. Because not all employees complete the requested information, you are being asked to do so by conducting a visual assessment of
the employee’s National Origin/Race.
*Verify Employer and Employee Sections’ information and complete Section 3, if applicable.
Client Name ________________________________________
Page 1 PEO074 09/2020
New Employee Packet
Employee •Read Sections 1 and 2 •Complete and sign Employee Signature section •Complete Section 3
SECTION 1. About Your Relationship With PaychexOne
The company for which you perform services (your Worksite Employer) has engaged Paychex Business Solutions or an affiliated company
(PaychexOne) to provide professional employer organization services under which you will be paid by PaychexOne and PaychexOne may make
certain benefits and other resources available and/or provide workers’ compensation coverage (including complying with Section 52-1-4 NMSA 1978 in
New Mexico). This is sometimes referred to as “co-employment” because PaychexOne performs certain employment-related functions, but
PaychexOne and your Worksite Employer are not joint employers. Your Worksite Employer directs and controls your day-to-day work and the conduct
of its business, receives the benefits of your services, and provides physical facilities, accommodations, and equipment. If you are represented by a
union, the relationship between you, your union, and your Worksite Employer is not affected by the relationship with PaychexOne.
You have no contract of employment with PaychexOne. Your Worksite Employer may enter into agreements with you. PaychexOne is not a party to or
responsible for such agreements and such agreements will not be affected by the relationship with PaychexOne or termination of that relationship.
Your Worksite Employer may provide benefits, incentive or bonus compensation, deferred compensation, profit sharing, severance pay, commissions,
sick or time off pay, and so on, but PaychexOne is not responsible for these things (although they may be provided through PaychexOne’s services) or
for anything promised to you by anyone other than PaychexOne.
If your Worksite employer fails to comply with its obligations to PaychexOne, at most PaychexOne will be responsible to pay you minimum wage and
applicable overtime for work you performed while covered under your Worksite Employer’s contract with PaychexOne except to the extent an
applicable law governing PaychexOne’s services expressly provides otherwise. However, if you are employed in South Carolina full wages due will be
paid but not any other consideration/benefit provided by the Worksite Employer. In Texas pursuant to section 91.032(c) of the Code the Worksite
Employer is solely obligated to pay any wages for which an obligation to pay is created by an agreement, contact, plan, or policy between it and you;
PaychexOne has not contracted to pay it.
In Hawaii PaychexOne is responsible for complying with laws relating to unemployment insurance, workers’ compensation, temporary disability
insurance, and prepaid health care coverage. In Montana PaychexOne reserves a right of direction and control over employees assigned to a
Worksite Employer’s location and retains authority to hire, terminate, discipline, and reassign employees, but your Worksite Employer retains sufficient
direction and control over employees necessary to conduct business and without which it would be unable to conduct business, discharge fiduciary
responsibilities, or comply with state licensing laws and has the right to accept or cancel the assignment of an employee. In Rhode Island, the
obligations of PaychexOne and the worksite employer are defined in section 5-75-7(D)(4) of R.I. General Laws. In South Carolina we are operating
under and subject to the Workers' Compensation Act of South Carolina. In case of accidental injury or death to an employee, the injured employee, or
someone acting on his or her behalf, shall notify their supervisor or designated safety contact at the Worksite Employer immediately. Failure to give
immediate notice may be the cause of serious delay in the payment of compensation to you or your beneficiaries and may result in failure to receive
any compensation benefits.
If you are or become eligible to receive group health/welfare benefits through PaychexOne: You will receive a benefit package including
materials explaining the benefits available and enrollment materials you must complete and submit; If you do not receive your benefit package
during your waiting period contact PaychexOne’s Benefits Department immediately (and before your coverage effective date); In order for
benefits to become effective you must complete any applicable waiting period and submit enrollment materials to PaychexOne prior to the coverage
effective date, failure to do so constitutes an election not to participate (if late enrollment is permitted pre-existing condition exclusions may apply to the
extent a participant cannot demonstrate continuous coverage by submitting a HIPAA Certificate of Creditable Coverage); Your elections will remain in
effect until the following annual enrollment period unless an eligible and submits required enrollment materials within 30 days of a qualifying event (see
your enrollment packet for details); By enrolling in group benefits you authorize deductions from your pay for required participant contributions
including deductions from your final pay if your employment terminates mid-month for coverages that extend through the full month which may include
medical, dental, and vision (Flexible Savings Account Plan and Short- and Long-Term Disability terminate concurrently with termination).
SECTION 2. Dispute Resolution Agreement
In the event of a legal dispute between you and Paychex Business Solutions or an affiliated company (PaychexOne) or your Worksite Employer arising
out of or in connection with your employment, application for employment, or separation from employment for which you are, were, or would be paid
through PaychexOne other than a claim for workers’ compensation benefits or unemployment benefits, you agree the following will apply:
Mandatory arbitration. Arbitration is an alternative to going to court. It is often faster, less expensive, and more convenient than going to court but
allows the same remedies that a court could grant. The US Supreme Court has held that employees may be required to arbitrate disputes under the
Federal Arbitration Act, the law which applies to this agreement to arbitrate. To the greatest extent allowed by law, ANY DISPUTE SUBJECT TO THIS
DISPUTE RESOLUTION AGREEMENT WILL BE RESOLVED EXCLUSIVELY THROUGH BINDING ARBITRATION before a neutral arbitrator. You may initiate
arbitration by filing with the American Arbitration Association, JAMS, or another mutually agreeable neutral arbitration service. To the extent not
inconsistent with this agreement, the rules of the neutral arbitration service for individual (not collective) employment disputes will apply. If required by
law, PaychexOne or your Worksite Employer will advance costs of arbitration. The arbitrator will: Have the authority to determine whether a dispute is
subject to this agreement to arbitrate; Be able to grant the same remedies as a federal court (but no more); Apply the Federal Rules of Evidence and
any applicable statutes of limitation; Render a reasoned, written decision based only on the evidence adduced and the law; and Grant reasonable
attorney fees and costs to the prevailing party if permitted by applicable law. Arbitration will be held in the capital or largest city of the state where you
were a Covered Employee under your relationship with PaychexOne or another mutually agreeable location, and PaychexOne and your Worksite
Employer may participate in any arbitration proceedings by telephone or video conference.
Waiver of jury trial. If for any reason a matter is not arbitrated, to the greatest extent allowed by law, THE MATTER WILL BE HEARD BY A JUDGE AND YOU
WAIVE ANY RIGHT TO TRIAL BY JURY. This provision will not apply in states where employers are by law not permitted to require employees to agree to it.
Waiver of class actions. To the greatest extent allowed by law, no matter how a matter subject to this Dispute Resolution Agreement is heard, you will
participate only in your individual capacity and not as a member or representative of a class. This provision will not apply in states where employers
are by law not permitted to require employees to agree to it.
Complaining to and cooperating with government agencies. Nothing in this Dispute Resolution Agreements prevents you from complaining to a
government agency or lawfully cooperating with a government agency investigation or restricts your right to act collectively with other employees under
Section 7 of the National Labor Relations Act.
Page 2 PEO074 09/2020
Other agreements (including collective bargaining agreements). This Dispute Resolution Agreement will not apply to a matter based on an agreement
with your Worksite Employer (for example, a nondisclosure or other restrictive covenant agreement, an employment contract, or an assignment of
intellectual property) if the agreement provides for another way to resolve disputes, as long as PaychexOne is not a party to the matter and an
insurance policy issued to PaychexOne is not providing coverage for the matter. If a dispute is subject to a collective bargaining agreement that is
inconsistent with this Dispute Resolution Agreement, the collective bargaining agreement will control. This Dispute Resolution Agreement controls over
any other conflicting agreement unless an attorney representing PaychexOne waives this Dispute Resolution Agreement in writing.
Survival of agreement. This Dispute Resolution Agreement will survive termination of your employment and of any relationship between you,
PaychexOne, and/or your Worksite Employer.
Changes in law etc. Laws governing resolution of employment-related disputes change frequently and may vary in different jurisdictions so this Dispute
Resolution Agreement must be flexible. With respect to any matter subject to this Dispute Resolution Agreement, if any part of this Dispute Resolution
Agreement is held invalid, impermissible, or unenforceable the remainder will continue in full force and effect, and the invalid, impermissible, or
unenforceable portion of this Dispute Resolution Agreement may be deemed automatically amended for purposes of that matter to the smallest extent
necessary to render it valid, permissible, and enforceable as near as possible to its original intent.
EMPLOYEE SIGNATURE
Name ___________________________________________________ Social Security Number _________ - _______ -
Address __________________________________________________ City _________________________ State ______ Zip __________
Telephone Number ( ________ ) _____________________________ Birth Date __________________________
Employee’s Personal Email Address _______________________________ Employee’s Work Email Address __________________________
I acknowledge and agree to the terms of this New Employee Packet including Section 2. Dispute Resolution Agreement. I agree that my signature
transmitted by fax or electronically or my electronic signature will be valid and binding as if it was an original signature.
Signature ________________________________________________ Date _______________________________
SECTION 3. EQUAL EMPLOYMENT OPPORTUNITY INFORMATION
We are subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In
order to comply with these laws, we invite you to voluntarily self-identify your race and ethnicity. Submission of this information is voluntary and
refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance
with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and
reported to the federal government for civil rights enforcement. When reported, data will not identify specific individuals.
❑ A visual assessment of the employee’s National Origin/Race has been made as the employee has not voluntarily provided this information.
Gender ❑ Female ❑ Male
National Origin (if you meet the definition of Hispanic or Latino, check the box below.)
❑ Hispanic or Latino (All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless
of race.)
Race (check the appropriate box)
❑ White (Not of Hispanic or Latino origin. All persons having
origins in any of the original peoples of Europe, North African or the
Middle East.)
❑ Native Hawaiian or Other Pacific Islander (Not of Hispanic or
Latino origin. All persons having origins in any of the original peoples
of Hawaii, Guam, Samoa, or other Pacific Islands.)
❑ Black or African American (Not of Hispanic or Latino origin.
All persons having origins in any of the Black racial groups of Africa
❑ American Indian or Alaskan Native (Not of Hispanic or Latino origin.
persons having origins in any of the original peoples of North and
South America, and who maintains tribal affiliation or community
attachment.)
❑ Asian (Not of Hispanic or Latino origin. All persons having
origins in any of the original peoples of the Far East, Southeast
Asia, or the Indian Subcontinent.)
❑ Two or More Races (Not of Hispanic or Latino origin. All
persons whoidentify with more than one of the five races listed
Mail or fax to:
970 Lake Carillon Drive, Suite 400 Fax: 1-800-668-7296 St. Petersburg, FL 33716
Internal Use Only
Underwriting Audit Updates
Workers’ Comp Class Code ________________________________
Benefit Insurance Class Code ______________________________
Audit completed by ______________________________________
Payroll Audit ___________________________________________
Client Name ____________________________________________________
Page 3 PEO074 09/2020
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N[f!?[aR_[NY!GRcR[bR!YNd(!=R[R_NYYf&!aNe!_Rab_[`!N[Q!_Rab_[!V[S\_ZNaV\[!N_R!
P\[SVQR[aVNY&!N`!_R^bV_RQ!Of!8\QR!`RPaV\[!0+*-(!
IUR!NcR_NTR!aVZR!N[Q!Re]R[`R`!_R^bV_RQ!a\!P\Z]YRaR!N[Q!SVYR!aUV`!S\_Z!dVYY!cN_f!
QR]R[QV[T!\[!V[QVcVQbNY!PV_PbZ`aN[PR`(!<\_!R`aVZNaRQ!NcR_NTR`&!`RR!aUR!
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S_\Z!f\b(!HRR!aUR!V[`a_bPaV\[`!S\_!f\b_!V[P\ZR!aNe!_Rab_[(
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0RRXEP!BE[EFPI!
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9SZIU!>E\MRK!8SF!0RRXEP!BE[EFPI!CEKI!"!AEPEU\
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"+*&***!'!!!+3&333 ,,* +&,,* +&3** ,&+** ,&,,* ,&,,* ,&,,* ,&,,* ,&.+* -&.+* .&*1* .&*1*
",*&***!'!!!,3&333 2/* +&3** ,&1-* ,&3-* -&*/* -&*/* -&*/* -&,.* .&,.* /&,.* /&3** /&3**
"-*&***!'!!!-3&333 3** ,&+** ,&3-* -&+-* -&,/* -&,/* -&..* .&..* /&..* 0&..* 1&+** 1&+**
".*&***!'!!!.3&333 +&*,* ,&,,* -&*/* -&,/* -&-1* -&/1* .&/1* /&/1* 0&/1* 1&/1* 2&,,* 2&,,*
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"2*&***!'!!!33&333 +&*0* -&,0* /&*3* 0&,3* 1&.,* 2&.,* 3&.,* +*&.,* ++&.,* +,&.,* +-&,0* +-&.0*
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",0*&***!'!,13&333 ,&*.* .&..* 0&.1* 1&21* 3&+3* +*&-3* ++&/3* +-&+,* +/&+,* +1&+,* +2&11* +3&11*
",2*&***!'!,33&333 ,&*.* .&..* 0&.1* 1&21* 3&+3* +*&1,* +,&1,* +.&1,* +0&1,* +2&1,* ,*&-1* ,+&-1*
"-**&***!'!-+3&333 ,&*.* .&..* 0&.1* 2&,** +*&-,* +,&-,* +.&-,* +0&-,* +2&-,* ,*&-,* ,+&31* ,,&31*
"-,*&***!'!-0.&333 ,&1,* /&3,* 2&1/* +*&3/* +-&*1* +/&*1* +1&*1* +3&*1* ,+&,3* ,-&/3* ,/&/.* ,0&2.*
"-0/&***!'!/,.&333 ,&31* 0&.1* 3&0** +,&+** +.&/-* +0&2-* +3&+-* ,+&.-* ,-&1-* ,0&*-* ,1&32* ,3&,2*
"/,/&***!N[Q!\cR_ -&+.* 0&2.* +*&+1* +,&21* +/&/** +2&*** ,*&/** ,-&*** ,/&/** ,2&*** -*&+/* -+&0/*
AMRKPI!SU!;EUUMIH!4MPMRK!AITEUEWIP\
6MKLIU!>E\MRK!8SF!
0RRXEP!BE[EFPI!
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9SZIU!>E\MRK!8SF!0RRXEP!BE[EFPI!CEKI!"!AEPEU\
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"*!'!!!!!3&333 ".0* "3.* "+&*,* "+&*,* "+&.1* "+&21* "+&21* "+&21* "+&21* ",&*.* ",&*.* ",&*.*
"+*&***!'!!!+3&333 3.* +&/-* +&0+* ,&*0* -&*0* -&.0* -&.0* -&.0* -&0.* -&2-* -&2-* -&2-*
",*&***!'!!!,3&333 +&*,* +&0+* ,&+-* -&+-* .&+-* .&/.* .&/.* .&1,* .&3,* /&++* /&++* /&++*
"-*&***!'!!!-3&333 +&*,* ,&*0* -&+-* .&+-* /&+-* /&/.* /&1,* /&3,* 0&+,* 0&-+* 0&-+* 0&-+*
".*&***!'!!!/3&333 +&21* -&.0* .&/.* /&/.* 0&03* 1&,3* 1&.3* 1&03* 1&23* 2&*2* 2&*2* 2&*2*
"0*&***!'!!!13&333 +&21* -&.0* .&03* /&23* 1&*3* 1&03* 1&23* 2&*3* 2&,3* 2&.2* 3&,0* +*&*0*
"2*&***!'!!!33&333 ,&*,* -&2+* /&*3* 0&,3* 1&.3* 2&*3* 2&,3* 2&.3* 3&.1* +*&.0* ++&,0* +,&*0*
"+**&***!'!+,.&333 ,&*.* -&2-* /&++* 0&-+* 1&/+* 2&.-* 3&.-* +*&.-* ++&.-* +,&.,* +-&/,* +.&0,*
"+,/&***!'!+.3&333 ,&*.* -&2-* /&++* 1&*-* 3&*-* +*&.-* ++&.-* +,&/2* +-&22* +/&+1* +0&,1* +1&-1*
"+/*&***!'!+1.&333 ,&-0* .&3/* 1&*-* 3&*-* ++&*-* +,&1-* +.&*-* +/&--* +0&0-* +1&3,* +3&*,* ,*&+,*
"+1/&***!'!+33&333 ,&1,* /&-+* 1&/.* 3&2.* +,&+.* +-&2.* +/&+.* +0&..* +1&1.* +3&*-* ,*&+-* ,+&,-*
",**&***!'!,.3&333 ,&31* /&20* 2&,.* +*&/.* +,&2.* +.&/.* +/&2.* +1&+.* +2&..* +3&1-* ,*&2-* ,+&3-*
",/*&***!'!-33&333 ,&31* /&20* 2&,.* +*&/.* +,&2.* +.&/.* +/&2.* +1&+.* +2&..* +3&1-* ,*&2-* ,+&3-*
".**&***!'!..3&333 ,&31* /&20* 2&,.* +*&/.* +,&2.* +.&/.* +/&2.* +1&+.* +2&./* +3&3.* ,+&,.* ,,&/.*
"./*&***!N[Q!\cR_ -&+.* 0&,-* 2&2+* ++&-+* +-&2+* +/&1+* +1&,+* +2&1+* ,*&,+* ,+&1** ,-&*** ,.&-**
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0RRXEP!BE[EFPI!
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9SZIU!>E\MRK!8SF!0RRXEP!BE[EFPI!CEKI!"!AEPEU\
!!!!!!
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"+*&***!'!!!+3&333 2-* +&3,* ,&+-* ,&,,* ,&,,* ,&02* -&02* .&*1* .&+-* .&--* .&..* .&..*
",*&***!'!!!,3&333 3-* ,&+-* ,&-/* ,&.-* ,&3** -&3** .&3** /&-.* /&/.* /&1.* /&2/* /&2/*
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".*&***!'!!!/3&333 +&*,* ,&/-* -&1/* .&2-* /&20* 1&*0* 2&,0* 2&2/* 3&*/* 3&,/* 3&-0* 3&-0*
"0*&***!'!!!13&333 +&21* .&*1* /&-+* 0&0** 1&2** 3&*** +*&,** +*&12* +*&32* ++&+2* ++&/2* +,&-2*
"2*&***!'!!!33&333 +&3** .&-** /&1+* 1&*** 2&,** 3&.** +*&0** ++&+2* ++&01* +,&01* +-&/2* +.&-2*
"+**&***!'!+,.&333 ,&*.* .&..* /&2/* 1&+.* 2&-.* 3&/.* ++&-0* +,&1/* +-&1/* +.&1/* +/&11* +0&21*
"+,/&***!'!+.3&333 ,&*.* .&..* /&2/* 1&-0* 3&-0* ++&-0* +-&-0* +.&1/* +0&*+* +1&-+* +2&/,* +3&0,*
"+/*&***!'!+1.&333 ,&*.* /&*0* 1&,2* 3&-0* ++&-0* +-&.2* +/&12* +1&.0* +2&10* ,*&*0* ,+&,1* ,,&-1*
"+1/&***!'!+33&333 ,&1,* /&3,* 2&+-* +*&.2* +,&12* +/&*2* +1&-2* +3&*1* ,*&-1* ,+&01* ,,&22* ,-&32*
",**&***!'!,.3&333 ,&31* 0&.1* 2&33* ++&-1* +-&01* +/&31* +2&,1* +3&30* ,+&,0* ,,&/0* ,-&11* ,.&21*
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"./*&***!N[Q!\cR_ -&+.* 0&2.* 3&/0* +,&+.* +.&0.* +1&+.* +3&0.* ,+&/-* ,-&*-* ,.&/-* ,/&3.* ,1&,.*
Direct Deposit Enrollment/Change Form*
Company Name and/or Client Number ________________________________________________________
Employee/Worker Name_____________________________ Employee/Worker Number __________
Employee/Worker: Retain a copy of this form for your records. Return the original to your employer/company.
Employer/Company: Please retain a copy of this document for your records.
COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS
–
PLEASE PRINT CLEARLY IN BLACK/BLUE INK ONLY
I wish to deposit (check one): _____% of Net Specific Dollar Amount $ _____________ .00 Remainder of Net Pay
I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions processed by
Paychex, Inc. I have reviewed the information provided and it is accurate to the best of my knowledge. My signature below indicates that
I have the authority to execute this document on behalf of the Client.
CONFIRMATION STATEMENT
Note:
Digital or Electronic Signatures are not acceptable.
* All fields are required except Employee/Worker Number.
** Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information specific to your account.
Checking/Savings Account Number**
Type of Account
Checking
Savings
Account holder's Name:
I wish to deposit (check one): _____% of Net Specific Dollar Amount $ _____________ .00 Remainder of Net Pay
I wish to deposit (check one): _____% of Net Specific Dollar Amount $ _____________ .00 Remainder of Net Pay
Financial Institution (“Bank”) Name
Routing/Transit Number
Type of Account
Checking
Savings
Account holder's Name:
Add new Replace existing account Last 4 digits of the existing account number
MM/DD/YY
Employer/Company Representative Printed Name: _______________________________
Employer/Company Representative Signature: _____________________________________ Date: ______________
Financial Institution (“Bank”) Name
Checking/Savings Account Number**
Add new Replace existing account Last 4 digits of the existing account number
Type of Account
Checking
Savings
Routing/Transit Number
Checking/Savings Account Number**
Add new Replace existing account Last 4 digits of the existing account number
Account holder's Name:
Routing/Transit Number
Financial Institution (“Bank”) Name
DP0002 10/20
Form Expires 10/31/23
PLEASE PRINT CLEARLY IN BLACK/BLUE INK ONLY
–
I authorize my employer/company to deposit my earnings into the bank account(s) specified above and, if necessary, to electronically
debit my account to correct erroneous entries. I certify my account(s) allow these transactions. Furthermore, I certify that the above listed
account number accurately reflects my intended receiving account. I agree that direct deposit transactions I authorize comply with all
applicable laws. My signature below indicates that I am agreeing that I am either the accountholder or have the authority of the
accountholder to authorize my employer/company make direct deposits into the named account. I understand that this authorization will
remain in full force and effect until I notify Company in writing that I wish to revoke my authorization.I understand that the Company
requires at least 5 business days prior notice to cancel this authorization.
Employee/Worker Signature
________________________________________
________________
Date:
MM/DD/YY
Update existing account
Update existing account
Update existing account
New
Health Insurance Marketplace Coverage
Options
and Your
Health Coverage
PART A: General
Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance
:
the Health
Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic
information about the new Marketplace and employmentbased health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The
Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible
for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance
coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or
offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on
your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for
a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be
eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does
not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.5% of your household income
for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the
Affordable Care Act, you may be eligible for a tax credit.
1
Note:
If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your
employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer
contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for
Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax
basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan description or
contact
.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit
HealthCare.gov
for more information, including an online application for health
insurance coverage and contact information for a Health Insurance Marketplace in your area.
1
An
employer-sponsored health plan meets the "minimum value standard"
if the
plan's
share of
the total allowed benefit costs covered
by
the plan
is no less
than 60 percent
of
such costs.
Form Approved
OMB No. 1210-0149
(expires 6-30-2023)
PART B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you decide to complete an
application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to
correspond to the Marketplace application.
3.
Employer name
4.
Employer Identification Number (EIN)
5.
Employer address
6.
Employer phone number
7.
City
8.
State
9. ZIP
code
10.
Who can we contact about employee health coverage at this job?
11. Phone number (if different from above) 12. Email address
Here is some basic information about health coverage offered by this employer:
•
As your employer, we offer a health plan to:
All employees. Eligible employees are:
Some employees. Eligible employees are:
•
With respect to dependents:
We do offer coverage. Eligible dependents are:
We do not offer coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be
affordable, based on employee wages.
** Even
if
your employer intends your coverage to be affordable, you may still be eligible for a premium discount
through the Marketplace. The Marketplace will use your household income, along with other factors, to
determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to
week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed
mid-year, or if you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace,
HealthCare.gov
will guide you through the process. Here's the
employer information you'll enter when you visit
HealthCare.gov
to find out if you can get a tax credit to lower your
monthly premiums.
The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for
employers, but will help ensure employees understand their coverage choices.
13.
Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in
the next 3 months?
Yes
(Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the
employee eligible for coverage? (mm/dd/yyyy) (Continue)
No
(STOP and return this form to employee)
14. D
oes the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15) No (STOP and return form to employee)
15. Fo
r the lowest-cost plan that meets the minimum value standard*
offered only to the employee
(don't include
family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she
received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on
wellness programs.
a.
How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't
know, STOP and return form to employee.
16. What change will the employer make for the new plan year?
Employer won't offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan
available only to the employee that meets the minimum value standard.* (Premium should reflect the
discount for wellness programs. See question 15.)
a.
How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
• An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the
plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
New
Health Insurance Marketplace Coverage
Options
and Your
Health Coverage
Form Approved
OMB No. 1210-0149
(expires 6-30-2023)
PART A: General
Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance
:
the Health
Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic
information about the new Marketplace.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The
Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible
for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance
coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or
offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on
your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for
a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be
eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does
not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.5% of your household income
for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the
Affordable Care Act, you may be eligible for a tax credit.
1
Note:
If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your
employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer
contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for
Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax
basis.
How Can I Get More Information?
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit
HealthCare.gov
for more information, including an online application for health
insurance coverage and contact information for a Health Insurance Marketplace in your area.
1
An
employer-sponsored health plan meets the "minimum value standard"
if the
plan's
share of
the total allowed benefit costs covered
by
the plan
is no less
than 60 percent
of
such costs.
PART B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you decide to complete an
application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered
to correspond to the Marketplace application.
3.
Employer name
4.
Employer Identification Number (EIN)
5.
Employer address
6.
Employer phone number
7.
City
8.
State
9. ZIP
code
10.
Who can we contact at this job?
11.
Phone number (if different from above)
12.
Email address
You are not eligible for health insurance coverage through this employer. You and your family may be able to obtain
health coverage through the Marketplace, with a new kind of tax credit that lowers your monthly premiums and with
assistance for out-of-pocket costs.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
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Peo074 New Employee Packet (Paychex)

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Completed 8 December 2020

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