West Virginia New Hire Reporting Form printable pdf download

West Virginia New Hire Reporting Form

Federal and state legislation requires all West Virginia employers, both public and private, to report to the New

Hire Reporting Center all newly hired, rehired, or returning to work employees. Information about new hire

reporting and online reporting is available on our website:

To ensure the highest level of accuracy, please print neatly in

Send completed forms to:

capital letters and avoid contact with the edges of the boxes.

West Virginia New Hire Reporting Center

The following will serve as an example:

PO Box 640098 Atlanta, GA 30364

ABC

123

Fax: (877) 625-4675

EMPLOYER INFORMATION

Federal Employer ID Number (FEIN): (Please enter the same FEIN used to report the employee's quarterly wages)

Employer Name:

Employer Address:

Employer City:

State:

Zip Code:

Employer Phone (optional):

Extension:

Employer Fax (optional):

Employer Contact Person Name (optional):

Email Address:

EMPLOYEE INFORMATION

Employee Social Security Number (SSN):

Employee First Name:

Middle Initial

Employee Last name:

Employee

Address:

Employee City:

State:

Zip Code:

Start Date MMDDYYYY:

Date of Birth MMDDYYYY (optional):

Is medical insurance available

Y/N

to employee? (optional):

Reports must be submitted within 14 days of hire or rehire date.

REPORTS WILL NOT BE PROCESSED IF REQUIRED INFORMATION IS MISSING

Questions? Call us toll-free at (877) 625-4669

West Virginia New Hire Reporting Form