SmartBenefits® Employer Enrollment Application
Customer Information:
Business Name:
Billing Address (if different from business address)
Address:
Address:
City:
City:
State:
[
,
AK - ALASKA
,
AL - ALABAMA
,
AR - ARKANSAS
,
AZ - ARIZONA
,
CA - CALIFORNIA
,
CO - COLORADO
,
CT - CONNECTICUT
,
DC - DISTRICT OF COLUMBIA
,
DE - DELAWARE
,
FL - FLORIDA
,
GA - GEORGIA
,
HI - HAWAII
,
IA - IOWA
,
ID - IDAHO
,
IL - ILLINOIS
,
IN - INDIANA
,
KS - KANSAS
,
KY - KENTUCKY
,
LA - LOUISIANA
,
MA - MASSACHUSETTS
,
MD - MARYLAND
,
ME - MAINE
,
MI - MICHIGAN
,
MN - MINNESOTA
,
MO - MISSOURI
,
MS - MISSISSIPPI
,
MT - MONTANA
,
NC - NORTH CAROLINA
,
ND - NORTH DAKOTA
,
NE - NEBRASKA
,
NH - NEW HAMPSHIRE
,
NJ - NEW JERSEY
,
NM - NEW MEXICO
,
NV - NEVADA
,
NY - NEW YORK
,
OH - OHIO
,
OK - OKLAHOMA
,
OR - OREGON
,
PA - PENNSYLVANIA
,
PR - PUERTO RICO
,
RI - RHODE ISLAND
,
SC - SOUTH CAROLINA
,
SD - SOUTH DAKOTA
,
TN - TENNESSEE
,
TX - TEXAS
,
UT - UTAH
,
VA - VIRGINIA
,
VT - VERMONT
,
WA - WASHINGTON
,
WI - WISCONSIN
,
WV - WEST VIRGINIA
,
WY - WYOMING
]
State:
[
,
AK - ALASKA
,
AL - ALABAMA
,
AR - ARKANSAS
,
AZ - ARIZONA
,
CA - CALIFORNIA
,
CO - COLORADO
,
CT - CONNECTICUT
,
DC - DISTRICT OF COLUMBIA
,
DE - DELAWARE
,
FL - FLORIDA
,
GA - GEORGIA
,
HI - HAWAII
,
IA - IOWA
,
ID - IDAHO
,
IL - ILLINOIS
,
IN - INDIANA
,
KS - KANSAS
,
KY - KENTUCKY
,
LA - LOUISIANA
,
MA - MASSACHUSETTS
,
MD - MARYLAND
,
ME - MAINE
,
MI - MICHIGAN
,
MN - MINNESOTA
,
MO - MISSOURI
,
MS - MISSISSIPPI
,
MT - MONTANA
,
NC - NORTH CAROLINA
,
ND - NORTH DAKOTA
,
NE - NEBRASKA
,
NH - NEW HAMPSHIRE
,
NJ - NEW JERSEY
,
NM - NEW MEXICO
,
NV - NEVADA
,
NY - NEW YORK
,
OH - OHIO
,
OK - OKLAHOMA
,
OR - OREGON
,
PA - PENNSYLVANIA
,
PR - PUERTO RICO
,
RI - RHODE ISLAND
,
SC - SOUTH CAROLINA
,
SD - SOUTH DAKOTA
,
TN - TENNESSEE
,
TX - TEXAS
,
UT - UTAH
,
VA - VIRGINIA
,
VT - VERMONT
,
WA - WASHINGTON
,
WI - WISCONSIN
,
WV - WEST VIRGINIA
,
WY - WYOMING
]
Zip:
Zip:
Contact Person:
Contact Person:
Contact Title:
[
,
Miss
,
Mr
,
Mrs
,
Ms
,
PhD
]
Phone:
(xxx-xxx-xxxx)
Phone:
(xxx-xxx-xxxx)
E-Mail:
E-Mail:
Business Type:
Private Sector
Federal/State/Local Government
Non-Profit
Employee Benefit Information (optional)
Approximate Number of Employees:
Benefit Category:
Pre-Tax Payroll Deduction
Employer Paid Benefit
Combination
Official Travel
Have you been working with a SmartBenefits Account Representative?
[
NO
,
AL WATSON
,
ALFONZA WATSON
,
ANTOINETTE RUCKER
,
JAMES BONGIORNO
,
JANIECE TIMMONS
,
KATHY TAGLIATI
,
XIAO P. YU
]
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 you bank to WMATA's bank. Complete your enrollment by returning the Customer Originated EFT agreement form we email to you.
Open Account -
Federal/state/local government accounts only. An account representative will contact you to make payment arrangements.
Credit Card-
IMPACT, Business 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