EOLWD-DFML

Type of Business(Required)

Business Type(Required)

Self-Employed Individuals Name(Required)

First Name Last Name

Residential Address of the Self-Employed Individual(Required)

Address Line 1 Address Line 2 City State ZIP Code Country

How is the self-employed individual paid?(Required)

If other, please explain(Required)

Does the business have an Employer Identification Number (EIN)?(Required)

Yes

Business Name(Required)

Business Employer Identification Number (EIN).(Required)

Date electing to opt-in PFML

This is the date you will begin to remit PFML Contributions. This date should reflect the beginning of a quarter (i.e. January 1, April 1, July 1, or October 1)

Average Massachusetts Workforce Count(Required)

Mailing Address(Required)

Address Line 1 Address Line 2 City State Zip Code

Point of Contact Information

Point of Contact Name(Required)

First Name Last Name

Point of Contact Email(Required)

Point of Contact Phone Number(Required)

Attachment

Notice of Election(Required)

Drop files here or

Max. file size: 50 MB.

Notarized Letter(Required)

Drop files here or

Max. file size: 50 MB.