ANNUAL COMPANY UPDATES

In order to insure our records are up to date, and include accurate information for year end, please take a moment to make any changes to the following information, as well as fill in any blank items. It would be helpful if you would indicate your SIC Code, if known, along with a brief description of your business.

Required Fields in BOLD

Company Name:      Account No:

Address Line 1:

Address Line 2:

City:      State:      Zip:

Mailing Address: (if different from above)

Address Line 1:

Address Line 2:

City:      State:      Zip:

Company Contact:

Telephone No:      Extention:

Fax No:

Cell Phone No:

Email:

Web Site:

SIC Code:      Click Here to Choose From Valid SIC Codes

Description of Business:   (i.e.: computer software consultants)

Tax Identification No:

Business Structure:   Corporation   LLC   Sole Proprietor   Partner   PC   Partnership

Waiting Period for New Employees:  No:      days   months

Or first of the month following waiting period:   No   Yes

How many hours constitutes a full time employee in your business:

Contribution Level by Employer:  Individual: %  Family: %

Information Completed by:

Title:

Date: