1Company Information2Billing Information3Broker/ Agent Contact(s)4Admin Provisions5Carrier Enrollment Contact Information6Medical Plan7Dental Plan 8Vision Plan9EAP10Medical FSA11HRA12Optional Services1314Acknowledgement & Signature COMPANY INFORMATIONIs This An Employee Navigator Group?* No Yes, Admin America will pull the medical, dental, & vision plan(s)and rate(s) information directly from Emplooyee Navigator Yes, but prefer to provide the medical, dental, & vision plan(s) and rate(s) information on this application For Employee Navigator groups, please ensure that Admin America is added as the COBRA vendor. Once we receive notice, we will pull plans and rates to began the integration process.Is This The First Year That The Company Is Offering Health Benefits?* No Yes Legal Company Name* DBA Employer Tax ID Number* Employer EntityCorporationS-CorporationLLCLLPPartnershipEmployer SizeEmployees CoveredCompany Phone#* Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address Same as previous Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Contact* First Last Primary Title Primary Email* Enter Email Confirm Email Primary PhoneIs There A Secondary Employer Contact?NoYesSecondary Employer Contact* First Last Secondary Title Secondary Email* Enter Email Confirm Email Secondary PhoneAre There Additional Employer Contacts?NoYesAdditional Employer ContactsContact NameContact Phone#Contact Email Contact NameContact Phone#Contact Email BILLING INFORMATIONBilling information for admin feesCOBRA Admin America Services Effective Date mm/dd/yyBroker Billed Broker Billed Broker Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Broker Billing Contact First Last Invoicing of Admin FeesBroker Billing Email Enter Email Confirm Email Invoicing of Admin FeesEmployer Billing Contact Is Same As:* Other - Complete Employer Billing Contact Information Below Primary Employer Contact Secondary Employer Contact Employer Billing Contact* First Last Invoicing of Admin FeesEmployer Billing Email* Enter Email Confirm Email Invoicing of Admin FeesEmployer Billing TelephoneInvoicing of Admin AmericaAre There Additional Employer Billing Contacts?NoYesAdditional Employer Billing ContactsContact NameContact Phone#Contact Email Additional Employer Billing ContactsContact NameContact Phone#Contact Email Method of Payment for Admin Fees* ACH (AA debits the Company's bank account) - fill out the AA ACH Authorization Form. Credit Card (Once invoice is emailed to billing contact(s), a link to our online payment system will be available) Company sends AA Payment via ACH. Company mails check to AA each billing cycle *For minimum sized groups we will bill on an annual basis. Otherwise, we will bill monthly. BROKER / AGENT CONTACT INFORMATIONAgent/BrokerYesN/AAgent Company* Agency Tax ID Number Agent Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Broker/Agent Name First Last Broker/Agent Email Account Rep(s)*First and Last NameEmail AddressPhone Number OTHER PLAN SERVICES AND ACKNOWLEDGEMENTSPlan Rates Start Date* mm/dd/yyPlan Rates End Date* mm/dd/yyGENERAL RIGHTS NOTIFICATIONThe Initical Notice or "General Rights Notice" is a document required by COBRA law to be sent to all new plan participants and covered dependents. The General Notice informs the plan participants and their dependents of their obligations should they experience a Qualifying Event. Willful failure to properly send this notice is subject to penalties and must be self-reported on IRS Form 8928. In addition, should an individual file suit against the employer for a perceived COBRA violation, the General Notice is often used as legal defense for the employer. Have all of the employees whom are benefit eligible received an Initial Notice?*YesNoIf No, Elect Fee*NoYesA Fee of $3.00 will be charged for each letter to a participant enrolled PRIOR to the Admin America COBRA Services Effective DateConsent* I agree to the $3.00 per Initial Notice fee.ONGOING CARRIER NOTIFICATION SERVICE OPTIONS AND ACKNOWLEDGEMENTSAuthorize the level of service you are electing.*Standard Carrier Notification ServiceBroker Notification ServiceSTANDARD CARRIER NOTIFICATION SERVICES: - COBRA Participant Reinstatements - Admin America notifies the appropriate insurance carriers of the need to reinstate-enroll COBRA participants following receipt of their COBRA Election Form and receipt of their Initial Premium Payment. *Please note: Admin America does not terminate coverage with Carriers. BROKER NOTIFICATION SERVICE: - COBRA Participant Reinstatements and Terms. - Admin America notifies the appropriate broker of the need to reinstate-enroll and terminate COBRA participants. The broker will initiate the appropriate activity with the carrier(s) upon notification. DISABILITY EXTENSION FEEIf a COBRA Participant is deemed disabled by the Social Security Administration, they may be eligible to remain on COBRA up to 29 months. If a COBRA participant chooses to extend their COBRA past their regular COBRA period, Employers have the option of increasing the standard 2% COBRA fee to 50% (Admin America retains 2%, the employer would receive the difference)In the event of a participant accepting the Disability Extension, what fee would the Employer want the participant to pay?50% (Recommended)2% Standard FeeHiddenWould you like to participate in GoHealth?YesNoAdmin America has partnered with GoHealth to offer alternative individual insurance coverage options to COBRA Qualified Beneficiaries. GoHealth is a private exchange solution that provides Qualified Beneficiaries with access to online decision support tools as well as telephone guidance from licensed insurance support tools as well as telephone guidance from licensed insurance advisors. GoHealth also offers Qualified Beneficiaries information about coverage and subsidies available through the public ACA Marketplace in their state. Admin America does not want to compete with any similar efforts that your insurance agent/broker may be utilizing to offer alternative insurance coverage to your COBRA Qualified Beneficiaries. If you would prefer that Admin America NOT offer this service, please select No. CARRIER ENROLLMENT CONTACTSCarrier Enrollment Contacts would be the enrollment individual contact or team E-Mail address and phone numbers where Admin America would send coverage reinstatements to.Medical Carrier Enrollment Contact Name or Team Name: Medical Carrier Enrollment Contact Email: Medical Carrier Enrollment Phone #Dental Carrier Enrollment Contact Name or Team Name: Dental Carrier Enrollment Contact Email: Dental Carrier Enrollment Phone #Vision Carrier Enrollment Contact Name or Team Name: Vision Carrier Enrollment Contact Email: Vision Carrier Enrollment Phone # MEDICAL PLAN INFORMATIONDoes Employer Offer Group Medical?*NoYesAre There Multiple Employer Divisions? No Yes Division Name*Division 1Division 2Division 3Division 4 Is Medical Plan Fully Insured or Self InsuredFully InsuredSelf InsuredDoes Medical Carrier require monthly paid thru date reports?NoYesMedical Enrollment Carrier Contact* The name of the invididual or team email that reinstatements would go to. Medical Enrollment Carrier Contact Email(s)* *VERY IMPORTANT to have accurate contact information- This would be the email for the contact to send reinstatement of coverage requests. Coverage will end for Qualified Beneficiaries*Date of TerminationLast Day of the Month15th or 31st RuleLast Day of Billing CycleMedical Plan Rates Start Date* mm/dd/yyMedical Plan Rates End Date* mm/dd/yyCheck To Upload Medical Age Banded Rates Upload Age Banded Rates 1 Medical Plan*Insurance CarrierMedical Plan Name 1 Medical PlanMedical Group#Employer Division (if applicable) 1 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more 2 Medical PlanInsurance CarrierMedical Plan Name 2 Medical PlanMedical Group#Employer Division (if applicable) 2 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more3 Medical PlanInsurance CarrierMedical Plan Name 3 Medical PlanMedical Group#Employer Division (if applicable) 3 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more4 Medical PlanMedical Plan NameMedical Group#Employer Division (if applicable) 4 Medical PlanInsurance CarrierMedical Plan Name 4 Medical PlanMedical Group#Employer Division (if applicable) 4 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or moreUpload Age Banded Medical Rate Sheet Drop files here or Select files Max. file size: 8 MB, Max. files: 3. DENTAL PLAN INFORMATIONDoes Employer Offer Group Dental?*NoYesIs Dental Plan Fully Insured or Self InsuredFully InsuredSelf InsuredDoes Dental Carrier require monthly paid thru date reports?NoYesDental Enrollment Carrier Contact* The name of the invididual or team email that reinstatements would go to. Dental Enrollment Carrier Contact Email(s)* *VERY IMPORTANT to have accurate contact information- This would be the email for the contact to send reinstatement of coverage requests. Dental Plan Information*Carrier NameGroup Account# Coverage will end for Qualified Beneficiaries*Date of TerminationLast Day of the Month15th or 31st RuleLast Day of Billing CycleDental Plan Rates Start Date* mm/dd/yyDental Plan Rates End Date* mm/dd/yyCheck To Upload Dental Age Banded Rates Upload Age Banded Rates 1 Dental Plan Name 1 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more2 Dental Plan Name 2 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more3 Dental Plan Name 3 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more4 Dental Plan Name 4 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or moreUpload Age Banded Dental Rate Sheet Drop files here or Select files Max. file size: 8 MB, Max. files: 3. VISION PLAN INFORMATIONDoes Employer Offer Group Vision?*NoYesIs Vision Plan Fully Insured or Self InsuredFully InsuredSelf InsuredDoes Vision Carrier require monthly paid thru date reports?NoYesVision Enrollment Carrier Contact* The name of the invididual or team email that reinstatements would go to. Vision Enrollment Carrier Contact Email(s)* *VERY IMPORTANT to have accurate contact information- This would be the email for the contact to send reinstatement of coverage requests. Vision Plan Information*Carrier NameGroup Account Number Vision Plan Rates Start Date* mm/dd/yyVision Plan Rates End Date* mm/dd/yyCoverage will end for Qualified Beneficiaries*Date of TerminationLast Day of the Month15th or 31st RuleLast Day of Billing CycleCheck To Upload Vision Age Banded Rates Upload Age Banded Rates 1 Vison Plan Name 1 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more2 Vison Plan Name 2 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more3 Vison Plan Name 3 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more4 Vison Plan Name 4 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or moreUpload Age Banded Rate Sheet Drop files here or Select files Max. file size: 8 MB, Max. files: 3. COBRA ELIGIBLE EAP PLAN INFORMATIONDoes Employer Offer a COBRA Eligible EAP Plan?*NoYes*Carrier NameGroup / Account NumberEnrollment Carrier Email Coverage will end for Qualified Beneficiaries*Date of TerminationLast Day of the Month15th or 31st RuleMonthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*Plan NameEE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more MEDICAL FSA PLAN INFORMATIONDoes Employer Offer an FSA Plan?*NoYesIs the FSA Plan Administered by Admin America?*YesNo*Plan AdministratorAdministrator Contact FSA Contact/Team Email* Enter Email Confirm Email FSA Administrator TelephoneFSA Plan Year*Plan Year Start DatePlan Year End Date Does FSA Administrator require monthly paid thru date reports?NoYes HRA PLAN INFORMATIONDoes Employer Offer an HRA Plan?NoYesIs the HRA Plan Administered by Admin America?*YesNo*Plan AdministratorAdministrator Contact HRA Contact Team Email* Enter Email Confirm Email HRA Administrator TelephoneHRA Plan Year*Plan Year Start DatePlan Year End Date Bundled Enrollment or Ability to Opt-Out Enrollment?*Ability to Opt-Out EnrollmentBundled EnrollmentOption 1 : Opt-Out (Recommended): Member may choose to Opt-Out of HRA Benefits. Option 2: Bundled Enrollment: Member cannot Opt-Out of the HRA when enrolled in Medical Plan. Would you like for Admin America to calculate the HRA rates?* No Yes Unless there are prior years claim utilization information, we will use 30% of the annual benefit. 1 HRA Monthly COBRA Premiums (Do Not Include 2% COBRA Administrative Fee)Plan NameEE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more 2 HRA Monthly COBRA Premiums (Do Not Include 2% COBRA Administrative Fee)Plan NameEE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more Does HRA Administrator require monthly paid thru date reports?NoYes ADDITIONAL OPTIONAL SERVICESAdditional fees may apply. COBRA Specific Rights Notice Letter* Accept Charges Do Not Accept Charges If Recently Terminated Employees (RTE) terminated prior to Admin America taking over administration and they have not received their initial Specific Rights Notice Letter, there will be a $20.00 charge for Admin America to send out the inotice. Consent I agree to the additional charges.EDI Feed No Yes Accept EDI Fees* Decline EDI Option COBRA QE/NPM Eligibility Files - $250 Consent* I agree to the EDI FeesEDI Vendor Name EDI Vendor Contact will need to send an email to edi@adminamerica.com to begin the integration process. Note Below Any Additional Information That We Should Be Aware Of Click Here to Access the Renewal KitClick Here to Access the Renewal KitClick Here to Access the Renewal CensusClick Here to Upload Renewal Information *Please Add the Name of the Company on Census for Identification CLIENT SIGNATURE Please complete the form and rates carefully. Any changes that cause Admin America Inc. to reprocess notifications to Qualified Beneficiaries and/or COBRA participants will result in a $20.00/per participant reprocessing fee. By entering your name below you are electronically signing this form. I understand the participant reprocessing fee stating above. The information I have supplied herein is accurate and should be used by Admin America Inc. for COBRA rates as of the date in which Admin America takes over. Your Name* Email* Date* MM slash DD slash YYYY CAPTCHA Δ
