Member intake

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Registration Process Stages

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Information Gathering

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

Your Position*

Business License Date*

When would you like your health insurance benefits to begin?*

FEIN/Tax ID*

Add multiple by using the + icon to the right.

Address Associated with FEIN

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Store Location(s)*

Note: If you have multiple FEINs, you will be treated as one entity based on common ownership.

Street Address

City

State

Zip Code

Total Employees

Store Opening Date

Number of Employees*

Employment Positions Type(s)*

Select All

Full Time

Part Time

Seasonal

In order to properly provide coverage and maintain COBRA compliance;
GIOA will need to receive your employee demographics on a weekly basis.
Members typically connect GIOA with their Payroll Provider Contact.

Payroll System in Use*

Payroll Provider Contact Name*

First Last

Payroll Provider Contact Email*

Payroll Provider Contact Phone

Upon submitting this form, you will soon be contacted by a GIOA Member Advocate who can answer any questions you may have about your new GIOA Membership.

NEED BLURB ABOUT DEMOGRAPHICS/CENSUS DATA - they will be directed to that (email in their inbox) after submitting this form)

Connect

Stay up to date with GIOA information hot off the grill.

Member intake

Registration Process Stages

In order to properly provide coverage and maintain COBRA compliance;GIOA will need to receive your employee demographics on a weekly basis. Members typically connect GIOA with their Payroll Provider Contact.

Connect

In order to properly provide coverage and maintain COBRA compliance;
GIOA will need to receive your employee demographics on a weekly basis.
Members typically connect GIOA with their Payroll Provider Contact.