CPA Verification LinkedInThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formCPA name(Required)This field is hidden when viewing the formCPA email address(Required)Your report and access status are sent here. This field is hidden when viewing the formCPA phone number(Required)This field is hidden when viewing the formFirm name(Required)This field is hidden when viewing the formFirm contact linePhone or email shown on the report. Optional.Business structure(Required) Sole proprietor S-Corp C-Corp State(Required)Select a stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingTax filing status(Required) Single Married filing jointly Head of household Annual net business profit (before salary or distributions)(Required)Please enter a number greater than or equal to 0.W-2 salary as % of profitS-Corp / C-Corp only. Typical range 50 to 80.Please enter a number from 50 to 80.Does this owner have W-2 employees?(Required)Drives the employee section below. No, owner only Yes, has employees Owner's current monthly health premium (enter 0 if uninsured)(Required)Please enter a number greater than or equal to 0.Current coverage tier(Required) Just me Me and spouse Me and children Full family Current coverage source(Required) ACA marketplace Spouse's plan Broker / private Household sizePlease enter a number greater than or equal to 1.Monthly PEO fee per benefits employee(Required)Flat monthly dollar per employee enrolled in benefits. If your proposal shows a percentage of payroll, divide the monthly dollar total by benefits employee count.Please enter a number greater than or equal to 0.Monthly PEO fee per payroll-only employeeEnter 0 if the PEO charges a single rate for all employees.Please enter a number greater than or equal to 0.Owner monthly premium under PEO plan(Required)Please enter a number greater than or equal to 0.Owner PEO coverage tier(Required) Just me Me and spouse Me and children Full family Open-market annual premium for comparisonOptional. Lead context only; not used in the calculation.Please enter a number greater than or equal to 0.Owner age range(Required) Under 50 50 to 59 60 to 63 64 plus Include dental and vision?(Required) Yes No Monthly dental and vision cost (owner)Owner only. Employee dental is not collected and shows zero in the report.Please enter a number greater than or equal to 0.Include 401(k)?(Required) Yes No Annual 401(k) plan administration cost (plan fee, not contribution amount)Please enter a number greater than or equal to 0.Full-time W-2 employees(Required)Please enter a number greater than or equal to 1.Part-time W-2 employeesPlease enter a number greater than or equal to 0.Employees enrolling in health coveragePlease enter a number greater than or equal to 0.Average annual salary per employeeSelect a rangeUnder $40k$40k to $60k$60k to $80k$80k to $100k$100k to $150k$150k plusEmployees on employee-only tierPlease enter a number greater than or equal to 0.Employees on employee and spouse tierPlease enter a number greater than or equal to 0.Employees on employee and children tierPlease enter a number greater than or equal to 0.Employees on full-family tierPlease enter a number greater than or equal to 0.Currently offer group health? Yes No Current monthly premium per employeePlease enter a number greater than or equal to 0.Current coverage tier (most employees) Employee only Employee and spouse Employee and children Employee and family Current employer contribution % 0% 25% 50% 75% 100% Employee monthly premium under PEO planPlease enter a number greater than or equal to 0.Desired employer contribution % under PEO 0% 25% 50% 75% 100% Offer dental to employees? Yes No Offer 401(k) to employees? Yes, with match consideration No Total average monthly payroll (all W-2 employees, excluding owner)Please enter a number greater than or equal to 0.Monthly workers comp premium (cost line display only, not included in tax calculation)Please enter a number greater than or equal to 0.