WELS Benefit Plans New Hire Information Form

"*" indicates required fields

Name*

First Middle Last

Sex*

Male

Female

Date of birth*

Social Security #*

Address*

Street Address Address Line 2 City State ZIP Code

Home phone

Home email*

Marital status*

Work phone

Work email

First name of spouse*

Cell phone*

Employment start*

Employment type*

Employment status*

Call status*

Annual employment salary*

SECA tax reimbursement

Annual housing allowance

Annual utilities allowance

Called/Employed by (Sponsoring organization name)*

Location city*

Location state*

Location zip code*

Name of individual completing this form*

First Last

Relationship to worker*

Self

Employer

Title / position*

Date*

WELS Benefit Plans Office: [email protected] or 414-256-3299
Ref: WELS Benefit Plans New Hire Information Form