Jane & Ben Shared Groups

Renewal Preparedness

This form will help ensure we have the most current information about your business as we approach your renewal date.

Company Name * Required

Your Name * Required

Job Title * Required

Phone * Required

Full-Time EEs

Part-Time EEs

Payroll Frequency

Payroll Provider

Employer Premium Contributions (EE/Dep)

Waiting Period for New Hires

Special Requests or Expected Changes