Biaw Health Insurance Trust Employer Participation Agreement (Page 2 of 4) in pdf

3. Employee Participation Requirements

A. Total number of employees on payroll, regardless of hours worked.................................................................................................................................. ___________

(Do not include COBRA participants.)

B. Employees not eligible for coverage on this plan:

1. Employees working fewer than the minimum hours as indicated in Section 2A...................... ___________

2. Employees who are not eligible by class as indicated in Section 2B......................................... ___________

3. Employees who have not completed the probationary period indicated in Section 2C............ ___________

(For new groups only, enter zero (0) if you selected “future” employees in Section 2E.)

4. Employees paid via IRS form 1099, or temporary, seasonal or substitute employees................___________

Subtotal B: ___________

C. Please indicate the number of employees waiving coverage for each of the following approved reasons:

1. Employees covered by Medicare as primary............................................................................. ___________

2. Employees covered by Military coverage (TriCare/Champus)................................................... ___________

3. Employees covered by other group coverage (e.g., spousal coverage, union, etc.)................... ___________

4. Employees covered by Tribal coverage..................................................................................... ___________

5. Employees waiving due to Christian Scientist beliefs............................................................... ___________

Subtotal C: ___________

Total eligible employees (A- Subtotal B - Subtotal C):

___________

D. Total number of enrolled employees...............................................................................................................................................................................

___________

E. Employees covered by your group under the Federal provisions of COBRA......................................................................................................................

___________

4. Federal Mandates: FMLA/TEFRA/DEFRA/COBRA/OBRA

(Family and Medical Leave Act/Tax Equity and Fiscal Responsibility Act of 1982/Consolidated Omnibus Budget Reconciliation Act

of 1985/Omnibus Budget Reconciliation Act of 1989 & 1993)

Yes

No

Did your company employ 50 or more full-time and/or part-time employees during each of 20 calendar weeks in the current or

preceding calendar year (January - December), and is it subject to FMLA? (If yes, you are required by federal law to comply with

FMLA provisions.)

All Trust Companies are subject to TEFRA/DEFRA, COBRA and OBRA laws.

5. Prior Coverage Information for New Groups

 If your group is renewing coverage, please check here and skip to Section 6. (For renewing groups, the carrier has your group’s prior coverage information on fi le.

 If your group is enrolling in the BIAW Trust for the fi rst time, please check here and complete this section in its entirety.

 Yes  No

Does your group have current group medical coverage?

If Yes, complete the following information:

Name of prior medical carrier: _____________________________

Date coverage began: _______________________

Date coverage canceled: _______________________

 Yes  No

Does your group have current group dental coverage?

If Yes, complete the following information:

Name of prior dental carrier: _______________________________

Date coverage began: _______________________

Date coverage canceled: _______________________

The probationary period for your prior carrier was: __________________

To receive credit for dental waiting periods, please attach a copy of the last billing statement from your prior carrier. Indicate the number of months (next to his or her name) that each

employee has been continuously covered (if over 6 months, show as 6+).

6. Employer Contribution

The employer will pay the following percentages of the monthly rate. The employer must pay a minimum 75% of total employee cost.

Employer Contribution

Medical Plan %

Dental Plan %

Employer pays for Employee:

Employer pays for Dependents: