Employer Notice Of Election - Healthpass

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HealthPass New York
61 Broadway, Suite 2705
Employer Notice of Election
New York, NY 10006
Phone (888) 313.7277
Fax (212) 252.7448
*Required information
Email
A. YOUR COMPANY
F
*
ull Name of Company*
Doing Business as (DBA) Name
______________________________________________________________________________________________________________________________________
*
Federal Tax ID Number*
Date Company Founded On (MM/DD/YYYY)
______________________________________________________________________________________________________________________________________
*
Organizational Type:
r“C” Corp
r“S” Corp
rSole Proprietorship
rPartnership
rNon-Profit
rChurch
rOther
*
Employer Industry:
rHigh Tech
rHealth
rLegal
rManufacturing
rRetail
rService
rTourism
rOther
*
*
*
Primary Contact Name
Primary Contact Phone Number/Ext.
Primary Contact Email
______________________________________________________________________________________________________________________________________
*
*
Street Address (No P.O. Boxes)
Suite
City/State/Zip
______________________________________________________________________________________________________________________________________
*
County or Borough
Fax Number
______________________________________________________________________________________________________________________________________
*
Billing Contact Name
Billing Street Address (if different)
Billing Suite
City/State/Zip
______________________________________________________________________________________________________________________________________
Billing Contact Phone/Ext.
Billing Contact Email
______________________________________________________________________________________________________________________________________
B. YOUR CURRENT BENEFITS
*
*
Total Number of Employees (Full and Part-Time) on Payroll
________ Total Number of Full Time Equivalent Employees*________ Number of Eligible Employees
________
*
Are you currently offering group health insurance?
If yes, name of Current Medical Carrier__________________________
rYes rNo
*
Have you had group dental coverage over the last 63 days?
rYes
rNo
*
Waiting period (Coverage Begins on the First of the Month Following)
r0 Months r1 Month r2 Months
*
How many hours per week must employees work to be eligible for coverage?
________ (Must be between 20 and 40 hours)
Are any enrollees Age 65+ (currently or within the next 90 days)?* rYes r No
*
Are any former employees currently covered under COBRA?
If yes, how many?*________
rYes rNo
*
Are any former employees currently covered under NY State Continuation (NYSC)?
rYes rNo If yes, how many?*________
*
Number of Enrollments with HealthPass
_________
*
Number of Eligible Employees who have Other Health Coverage
________
*
Number of Employees covered by Collective Bargaining Agreement
_________
C. YOUR BENEFITS WITH HEALTHPASS
Tier structure for Medical:* xFour Tier (All Carriers)
Tier structure for Dental:* rTwo Tier rFour Tier (Solstice Four Tier only) rNot Interested
Tier structure for Vision:* rTwo Tier rFour Tier (Solstice Four Tier only) rNot Interested
Offer Life/ADD/LTD EverGuard and/or EverGuard Plus:* rYes rNo
COBRA/NYSC (Included Service):* r I would like to participate in COBRA/NYSC service r I would like to opt out of COBRA/NYSC service
COBRA (Federal) or NYSC (State):* rFederal rState
Requested Effective Date* ___________________(Must be 1st of the month only)
r
I have attached an NYS-45 or applicable tax form from the most recent quarter*
Tax docs must be notated with the following only: FT (Full Time) PT (Part Time) U (Union) T (Termed) S (Seasonal)
D. BROKER & GA INFORMATION
Broker commission splits must total 100%.
Pay Commission To
Broker Name ________________________________________
Broker ID# ___________________ _______________%
Broker Name ________________________________________
Broker ID# ___________________ ________________%
General Agency Name (if applicable) ________________________________________
GA ID#
_____________________________________
General Agency Representative Name _______________________________________
V2 of 2 10/16
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