Form Loc20 - Maine New Hire Reporting
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1Maine New Hire Reporting Form
DOL State ID: _________________________
Employer Name and Address:
Federal ID: _________________________
Employee Information:
1. SSN: ________________________ Employee Name: ________________________________________
Employee Address: ____________________________________________________________________
City: __________________________________ State: ___________________ Zip: ________________
Date of Birth: ________________ Date of Hire: ______________ Date of Termination: ______________
Home Phone: _____________________________ Work Phone:
_______________________________
Re-Hire: Y /
N
Occupation: _________________________________________________________
Pay Frequency: HR / WK / MO / YR
Gross Amount: $__________________________________
Insurance Available for Employee? Y / N
Cost: $__________ Employee Covered? Y / N
Insurance Available for Dependent(s)? Y / N Cost: $__________ Dependent covered? Y / N
2. SSN: ________________________ Employee Name: ________________________________________
Employee Address: ____________________________________________________________________
City: __________________________________ State: ___________________ Zip: ________________
Date of Birth: ________________ Date of Hire: ______________ Date of Termination: ______________
Home Phone: _____________________________ Work Phone:
_______________________________
Re-Hire: Y /
N
Occupation: _________________________________________________________
Pay Frequency: HR / WK / MO / YR
Gross Amount: $__________________________________
Insurance Available for Employee? Y / N
Cost: $__________ Employee Covered? Y / N
Insurance Available for Dependent(s)? Y / N Cost: $__________ Dependent covered? Y / N
3. SSN: ________________________ Employee Name: ________________________________________
Employee Address: ____________________________________________________________________
City: __________________________________ State: ___________________ Zip: ________________
Date of Birth: ________________ Date of Hire: ______________ Date of Termination: ______________
Home Phone: _____________________________ Work Phone:
_______________________________
Re-Hire: Y /
N
Occupation: _________________________________________________________
Pay Frequency: HR / WK / MO / YR
Gross Amount: $__________________________________
Insurance Available for Employee? Y / N
Cost: $__________ Employee Covered? Y / N
Insurance Available for Dependent(s)? Y / N Cost: $__________ Dependent covered? Y / N
Mail to: DSER – New Hire Reporting Program
Or Fax to: (207) 287-6882
11 State House Station
(800) 437-9611
Augusta, ME 04330-0011
LOC20 R092013
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Parent category: Business