SmartBenefits® Enrollment Application for Businesses

Customer Information:
Business Name: Billing Address (if different from business address)
Address: Address:
City: City:
State: State:
Zip: Zip:
Contact Person: Contact Person:
Contact Title:    
Phone: (xxx-xxx-xxxx) Phone: (xxx-xxx-xxxx)
E-Mail: E-Mail:
Business Type: Private SectorFederal GovtNon-ProfitOther Govt
Do you need to comply with DCís Commuter Benefits law? YesNo
Where did you hear about us?
This account is for: EmployeesNon-Employees
Employee Benefit Information
Approximate Number of Employees: (optional)
Have you been working with a SmartBenefits Account Executive?  
Method of Payment (select one):
ACH - WMATA Originated (Recommended) Authorizes WMATA (Metro) to automatically draw the payment for your order each month from your designated bank account. Take advantage of this convenient process and complete your enrollment by returning the authorization form we email to you.

ACH - Customer Originated You manually perform an electronic funds transfer each month from your bank to WMATA's bank.

Open Account - Federal/state/local government accounts only. An account representative will contact you to make payment arrangements.

Credit Card- Visa, MasterCard, Discover, American Express. An account representative will contact you to make payment arrangements. Credit card payments are subject to a (3)% convenience fee.

 
SmartBenefits® Terms and Conditions
For Employers
For Non-Employer Providers
 

By submitting, you agree to be bound by the terms and conditions referenced in this application. Yes No