Annual Group Information Form - Access Request for Employers

*Required Field

Company Name

Federal Tax Identification Number

Group & Sub Group Numbers You will Access

Do you already have a web account for this group?


1st Choice for Username

2nd Choice for Username

Your Name

Phone Number

Email Address

Company's Authorization

Name of Person Granting Authorization:(e.g., HR Manager or Payroll Manager

Please allow five business days for us to process your request.  We will notify you once your web account is ready.