Lang Financial Group, Inc. human resource / employment management administration

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Please note that this online form is 6 pages long. If you would prefer, you can download and print a PDF version of the request packet HERE, to be filled out and mailed in to our office.

Contact Information

Name:
Position:
E-mail:
Phone:
Fax:

Company Information

Company Name:
Street Address:
City:
State:
Zip Code:
Nature of your business:
SIC Code, if known:
Names and addresses of any affiliates or subsidiaries to be included:
Total Employees on Payroll:
Number of Eligible Employees:
Number of Eligible Employees Electing Coverage:
Number of Retired Employees Electing Coverage:
Do You have Existing Group Health Coverage?
Name of Current Group Health Insurance Company:
Month of Renewal for Current Coverage:

COBRA Participants

Number of COBRA Participants: