Profile - Member Enrollment

Participating Employer Peppermint Pooled Employer Plan Setup Form

Primary Plan Contact Already a member?

Full Name *

Home Address *

Preferred Phone *

Fax

Authorized Signer on Behalf of Employer? *

Yes

Grant Web Access to the Plan? *

Yes

Additional Plan Payroll Contact (If different than business primary contact)

Contact Name

Contact Role Type

Contact Email

Contact Direct Phone

Contact Fax

Authorized Signer on Behalf of Employer?

Yes

Grant Employer-Level Access to the Plan?

Yes

Company Info

Your employer has asked to collect a few items related to your employment.

Business Information

We need to collect some basic information about your business

Full Legal Business Name *

Business Address *

Business Phone Number *

Business Fax Number

Business EIN *

Fiscal Year End *

Entity Type *

Entity Effective Date *

Plan Information

We need to collect some plan information

Full Legal Plan Name

New or Existing Plan

Plan Type

Plan Effective Date *

First Payroll File Upload* *

* Enter the Check Date for the first payroll period for which salary deferral contributions will be made to employee accounts on the Peppermint 401k recordkeeping/investment platform.

Payroll Provider Information

Note: Providing this additional contact information is optional

Type of Provider

Company Name *

Address

Contact Name

Contact Email

Contact Phone

Contact Fax

Special Comments and Instructions

Comments

Create Account

Use your email address to sign into the member portal after you have enrolled.

Email Address *

Confirm Email Address *

Password *

Confirm Password *

Continue

Member Name

DOB Resident Email

Member ID Group 8840850