Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694819386944.pdf (Antigua and Barbuda)
P.O.

Box 424 Nevis Street St. John’s Antigua Telephone: (268) 481-6200/6216-19481-6367/8 Fax: 481-6370/30 MEDICAL BENEFITS SCHEME EMPLOYER REGISTRATION FORM Employer Registration No.

1. Business Name ……………………………………………………………............................................................. 2.

Trade Name (if applicable)……………………………………………………….……….........................……...….

3. Business License No.

……………………………….….. 4.

No.

of persons employed: Male…… Female……… 5.


Location where main activities will be or are carried on: (be specific)…………………………….……....…..... …………………………………………………........................................................................................................ 6.

Mailing address………………………………………………………P.O.

Box No...………………….……..….

7.

Email address ………………………………………………………………………………………………….….

8. Business Phone …………………..…......

Mobile Phone …..……………….....Fax No……………….…….….


9. Business commence date………..……………….

10.

Date wages were first paid………….………….……… 11.

SECTOR: Private Government Quasi Government 12.

TYPE OF OWNERSHIP: Sole Proprietor Partnership Corporation/ Limited Liability Company 13.

OWNERS & DIRECTORS : Name(s) Address Title Phone No.

/Cell ..................................................... ………………………… …………….…..… ……………….…….….. ………………………………….. ………………………….

.……………….….

…………….………..….. ………………………………….. ………………………….


…………………… …………………....…….

………………………………….. ………………………….

…………………… ………………………….. 14.

Was the business acquired from someone or previously registered with the Scheme?

Yes No If yes, complete lines 15 -17 15.

Previous Business Name ………………………………………………………………………………..….......... 16.

Previous Business Owner Name and Address …………….……………………………………………….….. 17.

Date of acquisition or Business Name Change………………………………………..…………………….….

18.
18.

List all business locations: Business/Trade Name Location Type of activity or product (be specific) …………………………………….

…………………………….

………………………..………………...……… …………………………………….

…………………………….

………………………….…………..…….…… 19.

Is your payroll computerized?

Yes No Name of Payroll software used: ……………………………………………………………….……..…..….…… Name (print)…………………………………..……… Signature……………………………..………..……..……..
Title of officer……………………………………….. Date…………………………………………..………..…… Overleaf - for official use OFFICIAL USE Registration Number: ……………………………………………………………………………………………..

Zone: ………………………………………………………………………………………………………………..

Dispatched documents: employer letter R3A D3 Deduction table Comments: ………………………………………………………………………………………………………….. ………………………………………………………………………………………………..………… ………………………………………………………………………………………………………….

Processed by: ………………………………………………………………… Date: …………………………….
____________________________________________________________________________________________ VERIFICATION Comments: ………………………………………………………………………………………………………….. ………………………………………………………………………………………………..………… ………………………………………………………………………………………………………….

I certify that the information contained in the application is complete and accurate, and all required documents have been submitted.

……………………………………………………….

Registration & Benefits Eligibility Supervisor Date: ………………………………………………….