EAP Request Form

Do you have Safety-Sensitive positions in your workforce?

Yes

Please select an option.

Do you have Satellite offices or worksites that are multi-state?

Yes

Please select an option.

Is your workforce unionized?

Yes

Please select an option.

If yes, please specify the states:

Please complete this field.

Number of Full-Time Employees (FTEs):

Please complete this field.

Estimated Number of COBRA Staff:

Please complete this field.

Estimated Number of Staff Ineligible for Benefits (e.g., PRN, PT, Interns, New Hires, etc.):

Please complete this field.

Primary HR Contact First Name:

Please complete this field.

Primary HR Contact Last Name:

Please complete this field.

Primary HR Contact Email:

Please complete this field.

Primary HR Contact Phone Number:

Please complete this field.

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