SmartBenefits® Employer Enrollment Application

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/State/Local GovernmentNon-Profit
Employee Benefit Information (optional)
Approximate Number of Employees:
Benefit Category: Pre-Tax Payroll DeductionEmployer Paid BenefitCombinationOfficial Travel
Have you been working with a SmartBenefits Account Representative?  
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.

 
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