Workplace Wellness Program

Transform your workers' compensation program with our comprehensive solution. Streamline payroll integration, reduce costs, and enhance employee well-being.

Download Census Template

Download our comprehensive census template to get started with accurate employee data collection.

Download Sequoia Census Excel Form Example

Workers' Compensation Saving Program Application

Today's Date*

Please enter today's date

Client Information

Company Name*

Please enter company name

Client Name*

Please enter client name

Client Email*

Please enter a valid email address

Client Phone*

Please enter a valid phone number

Please complete the form in its entirety with detailed information.

Payroll Contact Information

Payroll Contact Person's Name*

Please enter payroll contact name

Payroll Contact Person's Email*

Please enter a valid email address

Payroll Contact Person's Phone*

Please enter a valid phone number

Company Details

Company Address*

Please enter company address

Industry*

Please enter industry

Number of Employees*

Please enter number of employees

Number of W-2 Employees

Current Payroll System

How often do you run payroll?*

Weekly (52 pay periods)

Bi-Weekly (26 pay periods)

Twice Monthly (24 pay periods)

Once a Month (12 pay periods)

Please select a payroll frequency

Does the Client currently offer Medical Insurance?*

Yes

Please select an option

Does client need language support?

Please provide the following document in .csv or excel format.

Required documents: Payroll Journal, W4, Census

Referred by

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