Employer Information Sheet
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1Employer Information Sheet
Employer Name and Tax No. _____________________________________________________
Notice to Employer:
Please fill out completely and return to: _____________________________________________
EMPLOYEE INFORMATION
Full name of employee: __________________________________________________________
Address: ______________________________________________________________________
SSN# : _______________ Date of Birth: _____________ Number of dependents: ___________
Date employed: _________________________ Job Title:_______________________________
Rate of pay: $____________ per _________ Average number of hours per week: ____________
How often paid (check one):
Weekly
Bi-weekly
Monthly
Semi-monthly
If paid Weekly/Bi-weekly, state day of the week paid: __________________________________
Date last paid: ___________________________
If paid Semi-monthly, state dates paid: _________________ Date last paid: ________________
If paid Monthly, state date paid: _______________________ Date last paid: ________________
Worksite address: _______________________________________________________________
Date Terminated: _______________________ If terminated, list the termination reason and the
name and address of the new employer, if known: _____________________________________
______________________________________________________________________________
Complete the Information below for the last four Pay Periods
Bonus/
Federal
Date Paid
Gross Wages
State Tax
FICA
Retirement
Net Wages
Commission
Tax
MEDICAL INSURANCE INFORMATION FOR MINOR CHILDREN
Available as of ______________________ (Date)
Not Available
Will be Available as of _______________________________________________________
Insurance Company Name: _______________________________________________________
Insurance Company Address: _____________________________________________________
Insurance Company Telephone Number: ____________________________________________
Policy Number: ________________________ Employee certificate/ID#: __________________
Type of Coverage: ______________________ Amount of Deductible: $___________________
Cost to employee to cover self/dependents: $_________________________________________
Individuals covered/effective date: _________________________________________________
_____________________________________________________________________________
Completed by: ______________________ Title: ______________________ Date: _________
When complete, return to the address shown below. Employer Telephone Number: _________
_____________________________________________________________________________
_____________________________________________________________________________
WAKE-DOM-13 Page 1 of 1 (Rev. 02/10)
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Parent category: Business