COBRA Renewal Portal

Employer Name
Legal Employer Name*
Does the Employer use a DBA Name?
- Yes
- No
DBA Employer Name

Save and Continue Later

Contact Details
Hidden
HIDDEN Have there been any Employer or Broker Contact Changes?
- There have NOT been any Employer or Broker Contact Changes
- Both Employer Contact and Broker Contact Changes
- Employer Contact Change
- Broker Contact Change
Employer Contact Name
First Last
Employer Contact Phone Number
Employer Contact Email
Broker Contact Name
First Last
Broker Contact Phone Number
Broker Contact Email
Is the Benefit Specific Contact the same as one of the contacts above?
A Benefit Specific Contact is an employer or broker contact whom participants should contact with any benefit-specific questions.

Any broker contacts must hold a current license. Admin America cannot advise on benefit information.
Benefit Specific Contact Name*
First Last
Benefit Specific Phone Number*
Benefit Specific Contact Email*

Save and Continue Later

Admin America Inc Assisted Open Enrollment Requirement
All of the following materials must be provided to Admin America Inc at least 30 days prior to the start of the new plan year.

Who should Admin America Inc invoice if Admin America Inc is to perform Open Enrollment after the 30-day deadline?

Other Invoice Contact Name
First Last
Other Invoice Phone Contact Number
Other Invoice Contact Email

Plan Summaries for each renewing or new plan (required even if no changes were made)

Drop files here or

Max. file size: 8 MB.

Current Carrier Enrollment/Change Forms for each plan

Drop files here or

Max. file size: 8 MB.

Save and Continue Later

Medical Renewal Details
IMPORTANT

Please complete the form and renewal rates carefully. All rates entered or uploaded must be final, and without the 2% fee. 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.

All rates entered or uploaded must be final, and without the 2% fee.

If irrelevant information is provided, Admin America may request additional information. Only Active Plans should be provided, no proposed plans should be included.

How will you supply rates? 1

Rate Type 1

Composite Rates 1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Age Banded Rates 1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Age Tier example: 25-36 yrs
Rate example: $685.00

Age Tier Rate

Member Specific Rates 1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Member Specific Tier Rate

Please upload the rates by selecting the "I will upload rates" option for question "How will you supply rates".

Rates Upload 1

Drop files here or

Max. file size: 100 MB.

Medical Carrier 1

Medical Insurance Renewal Date 1
MM slash DD slash YYYY

Benefit Termination Date 1

Benefit Termination Date: Other 1
Enter the benefit termination date

Medical Plan Name 1

Medical Plan Type 1

Medical Plan Type: Other 1
Enter the Medical Plan Type

Plan Identifier 1

Group Number 1*
If Group Number is not available, enter TBD. It is your responsibility to provide the group number when it becomes available. If we do not have your group number, then reinstatements will not be completed by Admin America directly with carriers.

COBRA Sub or Account Structure (if applicable) 1

Is this a new Medical Insurance Plan? 1

Yes

No

Have any of the below changed? 1
Note: The Carrier Contact is the individual at the carrier to whom you send Enrollments
Enrollment Carrier Contact
Plan Funding
None of these have changed

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name 1
First Last
Enrollment Carrier Contact Email 1

Enrollment Carrier Contact Phone 1

Plan Funding 1

Would you like to add another Medical Insurance Plan? 1*

Yes

No

Save and Continue Later

Medical Insurance: Multiple Plan Details
Please complete the form and renewal 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.

Do all of your Medical Insurance Plans share the same Medical Insurance Carrier?

Yes

No

Do all of you Medical Insurance Plans share the same Renewal Date?

Yes

No

Save and Continue Later

Medical Insurance Additional Plan
Please complete the form and renewal 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.

Medical Carrier2M

Is this a New Medical Carrier? 2

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Medical Insurance Renewal Date 2M
MM slash DD slash YYYY

Medical Plan Name 2

Medical Plan Type 2
Medical Plan Type: Other 2
Enter the Medical Plan Type

Plan Identifier 2

Group Number 2

COBRA Sub or Account Structure (if applicable) 2

Is this a new Medical Insurance Plan? 2.1

Yes

No
Is this a new Medical Insurance Plan? 2.2

Yes

No

Has the Enrollment Carrier Contact Changed? 2

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name 2.1
First Last
Enrollment Carrier Contact Name 2.2
First Last
Enrollment Carrier Contact Email 2.1

Enrollment Carrier Contact Email 2.2

Enrollment Carrier Contact Phone 2.1
Enrollment Carrier Contact Phone 2.2

Have the Rates changed? 2

Yes

No

Rate Type 2.1
Rate Type 2.2
Rate Type 2.3
Rate Type: Other 2.1
Enter the Rate Type

Rate Type: Other 2.2
Enter the Rate Type

Rate Type: Other 2.3
Enter the Rate Type

Composite Rates 2.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 2.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 2.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload 2.1

Drop files here or

Max. file size: 100 MB.

Rates Upload 2.2

Drop files here or

Max. file size: 100 MB.

Rates Upload 2.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Medical Insurance Plan? 2*

Yes

No

Save and Continue Later

Medical Insurance Additional Plan
Please complete the form and renewal 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.

Medical Carrier3M

Is this a New Medical Carrier? 3

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Medical Insurance Renewal Date 3M
MM slash DD slash YYYY

Medical Plan Name 3

Medical Plan Type 3
Medical Plan Type: Other 3
Enter the Medical Plan Type

Plan Identifier 3

Group Number 3

COBRA Sub or Account Structure (if applicable) 3

Is this a new Medical Insurance Plan? 3.1

Yes

No
Is this a new Medical Insurance Plan? 3.2

Yes

No

Has the Enrollment Carrier Contact Changed? 3

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name 3.1
First Last
Enrollment Carrier Contact Name 3.2
First Last
Enrollment Carrier Contact Email 3.1

Enrollment Carrier Contact Email 3.2

Enrollment Carrier Contact Phone 3.1
Enrollment Carrier Contact Phone 3.2

Have the Rates changed? 3

Yes

No

Rate Type 3.1
Rate Type 3.2
Rate Type 3.3
Rate Type: Other 3.1
Enter the Rate Type

Rate Type: Other 3.2
Enter the Rate Type

Rate Type: Other 3.3
Enter the Rate Type

Composite Rates 3.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 3.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 3.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload 3.1

Drop files here or

Max. file size: 100 MB.

Rates Upload 3.2

Drop files here or

Max. file size: 100 MB.

Rates Upload 3.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Medical Insurance Plan? 3*

Yes

No

Save and Continue Later

Medical Insurance Additional Plan
Please complete the form and renewal 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.

Medical Carrier4M

Is this a New Medical Carrier? 4

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Medical Insurance Renewal Date 4M
MM slash DD slash YYYY

Medical Plan Name 4

Medical Plan Type 4
Medical Plan Type: Other 4
Enter the Medical Plan Type

Plan Identifier 4

Group Number 4

COBRA Sub or Account Structure (if applicable) 4

Is this a new Medical Insurance Plan? 4.1

Yes

No
Is this a new Medical Insurance Plan? 4.2

Yes

No

Has the Enrollment Carrier Contact Changed? 4

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name 4.1
First Last
Enrollment Carrier Contact Name 4.2
First Last
Enrollment Carrier Contact Email 4.1

Enrollment Carrier Contact Email 4.2

Enrollment Carrier Contact Phone 4.1
Enrollment Carrier Contact Phone 4.2

Have the Rates changed? 4

Yes

No

Rate Type 4.1
Rate Type 4.2
Rate Type 4.3
Rate Type: Other 4.1
Enter the Rate Type

Rate Type: Other 4.2
Enter the Rate Type

Rate Type: Other 4.3
Enter the Rate Type

Composite Rates 4.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 4.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 4.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload 4.1

Drop files here or

Max. file size: 100 MB.

Rates Upload 4.2

Drop files here or

Max. file size: 100 MB.

Rates Upload 4.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Medical Insurance Plan? 4*

Yes

No

Save and Continue Later

Medical Insurance Additional Plan
Please complete the form and renewal 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.

Medical Carrier5M

Is this a New Medical Carrier? 5

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Medical Insurance Renewal Date 5M
MM slash DD slash YYYY

Medical Plan Name 5

Medical Plan Type 5
Medical Plan Type: Other 5
Enter the Medical Plan Type

Plan Identifier 5

Group Number 5

COBRA Sub or Account Structure (if applicable) 5

Is this a new Medical Insurance Plan? 5.1

Yes

No
Is this a new Medical Insurance Plan? 5.2

Yes

No

Has the Enrollment Carrier Contact Changed? 5

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name 5.1
First Last
Enrollment Carrier Contact Name 5.2
First Last
Enrollment Carrier Contact Email 5.1

Enrollment Carrier Contact Email 5.2

Enrollment Carrier Contact Phone 5.1
Enrollment Carrier Contact Phone 5.2

Have the Rates changed? 5

Yes

No

Rate Type 5.1
Rate Type 5.2
Rate Type 5.3
Rate Type: Other 5.1
Enter the Rate Type

Rate Type: Other 5.2
Enter the Rate Type

Rate Type: Other 5.3
Enter the Rate Type

Composite Rates 5.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 5.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 5.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload 5.1

Drop files here or

Max. file size: 100 MB.

Rates Upload 5.2

Drop files here or

Max. file size: 100 MB.

Rates Upload 5.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Medical Insurance Plan? 5*

Yes

No

Save and Continue Later

Medical Insurance Additional Plan
Please complete the form and renewal 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.

Medical Carrier6M

Is this a New Medical Carrier? 6

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Medical Insurance Renewal Date 6M
MM slash DD slash YYYY

Medical Plan Name 6

Medical Plan Type 6
Medical Plan Type: Other 6
Enter the Medical Plan Type

Plan Identifier 6

Group Number 6

COBRA Sub or Account Structure (if applicable) 6

Is this a new Medical Insurance Plan? 6.1

Yes

No
Is this a new Medical Insurance Plan? 6.2

Yes

No

Has the Enrollment Carrier Contact Changed? 6

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name 6.1
First Last
Enrollment Carrier Contact Name 6.2
First Last
Enrollment Carrier Contact Email 6.1

Enrollment Carrier Contact Email 6.2

Enrollment Carrier Contact Phone 6.1
Enrollment Carrier Contact Phone 6.2

Have the Rates changed? 6

Yes

No

Rate Type 6.1
Rate Type 6.2
Rate Type 6.3
Rate Type: Other 6.1
Enter the Rate Type

Rate Type: Other 6.2
Enter the Rate Type

Rate Type: Other 6.3
Enter the Rate Type

Composite Rates 6.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 6.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 6.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload 6.1

Drop files here or

Max. file size: 100 MB.

Rates Upload 6.2

Drop files here or

Max. file size: 100 MB.

Rates Upload 6.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Medical Insurance Plan? 6*

Yes

No

Save and Continue Later

Medical Insurance Additional Plan
Please complete the form and renewal 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.

Medical Carrier7M

Is this a New Medical Carrier? 7

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Medical Insurance Renewal Date 7M
MM slash DD slash YYYY

Medical Plan Name 7

Medical Plan Type 7
Medical Plan Type: Other 7
Enter the Medical Plan Type

Plan Identifier 7

Group Number 7

COBRA Sub or Account Structure (if applicable) 7

Is this a new Medical Insurance Plan? 7.1

Yes

No
Is this a new Medical Insurance Plan? 7.2

Yes

No

Has the Enrollment Carrier Contact Changed? 7

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name 7.2
First Last
Enrollment Carrier Contact Name 7.1
First Last
Enrollment Carrier Contact Email 7.1

Enrollment Carrier Contact Email 7.2

Enrollment Carrier Contact Phone 7.1
Enrollment Carrier Contact Phone 7.2

Have the Rates changed? 7

Yes

No

Rate Type 7.1
Rate Type 7.2
Rate Type 7.3
Rate Type: Other 7.1
Enter the Rate Type

Rate Type: Other 7.2
Enter the Rate Type

Rate Type: Other 7.3
Enter the Rate Type

Composite Rates 7.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 7.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 7.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload 7.1

Drop files here or

Max. file size: 100 MB.

Rates Upload 7.2

Drop files here or

Max. file size: 100 MB.

Rates Upload 7.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Medical Insurance Plan? 7*

Yes

No

Save and Continue Later

Medical Insurance Additional Plan
Please complete the form and renewal 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.

Medical Carrier8M

Is this a New Medical Carrier? 8

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Medical Insurance Renewal Date 8M
MM slash DD slash YYYY

Medical Plan Type 8
Medical Plan Type: Other 8
Enter the Medical Plan Type

Plan Identifier 8

Group Number 8

COBRA Sub or Account Structure (if applicable) 8

Is this a new Medical Insurance Plan? 8.1

Yes

No
Is this a new Medical Insurance Plan? 8.2

Yes

No

Has the Enrollment Carrier Contact Changed? 8

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name 8.1
First Last
Enrollment Carrier Contact Name 8.2
First Last
Enrollment Carrier Contact Email 8.1

Enrollment Carrier Contact Email 8.2

Enrollment Carrier Contact Phone 8.1
Enrollment Carrier Contact Phone 8.2

Have the Rates changed? 8

Yes

No

Rate Type 8.1
Rate Type 8.2
Rate Type 8.3
Rate Type: Other 8.1
Enter the Rate Type

Rate Type: Other 8.2
Enter the Rate Type

Rate Type: Other 8.3
Enter the Rate Type

Composite Rates 8.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 8.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 8.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload 8.1

Drop files here or

Max. file size: 100 MB.

Rates Upload 8.2

Drop files here or

Max. file size: 100 MB.

Rates Upload 8.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Medical Insurance Plan? 8*

Yes

No

Save and Continue Later

Medical Insurance Additional Plan
Please complete the form and renewal 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.

Medical Carrier9M

Is this a New Medical Carrier? 9

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Medical Insurance Renewal Date 9M
MM slash DD slash YYYY

Medical Plan Type 9
Medical Plan Type: Other 9
Enter the Medical Plan Type

Plan Identifier 9

Group Number 9

COBRA Sub or Account Structure (if applicable) 9

Is this a new Medical Insurance Plan? 9.1

Yes

No
Is this a new Medical Insurance Plan? 9.2

Yes

No

Has the Enrollment Carrier Contact Changed? 9

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name 9.1
First Last
Enrollment Carrier Contact Name 9.2
First Last
Enrollment Carrier Contact Email 9.1

Enrollment Carrier Contact Email 9.2

Enrollment Carrier Contact Phone 9.1
Enrollment Carrier Contact Phone 9.2

Have the Rates changed? 9

Yes

No

Rate Type 9.1
Rate Type 9.2
Rate Type 9.3
Rate Type: Other 9.1
Enter the Rate Type

Rate Type: Other 9.2
Enter the Rate Type

Rate Type: Other 9.3
Enter the Rate Type

Composite Rates 9.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 9.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 9.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload 9.1

Drop files here or

Max. file size: 100 MB.

Rates Upload 9.2

Drop files here or

Max. file size: 100 MB.

Rates Upload 9.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Medical Insurance Plan? 9*

Yes

No

Save and Continue Later

Medical Insurance Additional Plan
Please complete the form and renewal 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.

Medical Carrier10M

Is this a New Medical Carrier? 10

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Medical Insurance Renewal Date 10M
MM slash DD slash YYYY

Medical Plan Type 10
Medical Plan Type: Other 10
Enter the Medical Plan Type

Plan Identifier 10

Group Number 10

COBRA Sub or Account Structure (if applicable) 10

Is this a new Medical Insurance Plan? 10.1

Yes

No
Is this a new Medical Insurance Plan? 10.2

Yes

No

Has the Enrollment Carrier Contact Changed? 10

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name 10.1
First Last
Enrollment Carrier Contact Name 10.2
First Last
Enrollment Carrier Contact Email 10.1

Enrollment Carrier Contact Email 10.2

Enrollment Carrier Contact Phone 10.1
Enrollment Carrier Contact Phone 10.2

Have the Rates changed? 10

Yes

No

Rate Type 10.1
Rate Type 10.2
Rate Type 10.3
Rate Type: Other 10.1
Enter the Rate Type

Rate Type: Other 10.2
Enter the Rate Type

Rate Type: Other 10.3
Enter the Rate Type

Composite Rates 10.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 10.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates 10.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload 10.1

Drop files here or

Max. file size: 100 MB.

Rates Upload 10.2

Drop files here or

Max. file size: 100 MB.

Rates Upload 10.3

Drop files here or

Max. file size: 100 MB.

Save and Continue Later

Dental Renewal Details
Please complete the form and renewal 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.

Dental Carrier D1

Is this a New Dental Carrier? D1

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Dental Insurance Renewal Date D1
MM slash DD slash YYYY

Dental Plan Name D1

Dental Plan Type D1
Dental Plan Type: Other D1
Enter the Dental Plan Type

Plan Identifier D1

Group Number D1

COBRA Sub or Account Structure (if applicable) D1

Is this a new Dental Insurance Plan? D1

Yes

No

Have any of the below changed? D1
Note: The Carrier Contact is the individual at the carrier to whom you send Enrollments
Benefit Termination Date
Enrollment Carrier Contact
Plan Funding
Rates
None of these have changed

Benefit Termination Date D1
Benefit Termination Date: Other D1

Enter the benefit termination date

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name D1
First Last
Enrollment Carrier Contact Email D1

Enrollment Carrier Contact Phone D1

Plan Funding D1

Rate Type D1
Rate Type: Other D1
Enter the Rate Type

Composite Rates D1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Upload the Rates by using the below

Rates Upload D1

Drop files here or

Max. file size: 100 MB.

Would you like to add another Dental Insurance Plan? D1*

Yes

No

Save and Continue Later

Dental Insurance: Multiple Plan Details
Please complete the form and renewal 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.

Do all of your Dental Insurance Plans share the same Dental Insurance Carrier?

Yes

No

Do all of you Dental Insurance Plans share the same Renewal Date?

Yes

No

Save and Continue Later

Dental Insurance Additional Plan
Please complete the form and renewal 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.

Dental Carrier 2M

Is this a New Dental Carrier? D2

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Dental Insurance Renewal Date 2M
MM slash DD slash YYYY

Dental Plan Name D2

Dental Plan Type D2
Dental Plan Type: Other D2
Enter the Dental Plan Type

Plan Identifier D2

Group Number D2

COBRA Sub or Account Structure (if applicable) D2

Is this a new Dental Insurance Plan? D2.1

Yes

No
Is this a new Dental Insurance Plan? D2.2

Yes

No

Has the Enrollment Carrier Contact Changed? D2

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name D2.1
First Last
Enrollment Carrier Contact Name D2.2
First Last
Enrollment Carrier Contact Email D2.1

Enrollment Carrier Contact Email D2.2

Enrollment Carrier Contact Phone D2.1
Enrollment Carrier Contact Phone D2.2

Have the Rates changed? D2

Yes

No

Rate Type D2.1
Rate Type D2.2
Rate Type D2.3
Rate Type: Other D2.1
Enter the Rate Type

Rate Type: Other D2.2
Enter the Rate Type

Rate Type: Other D2.3
Enter the Rate Type

Composite Rates D2.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates D2.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates D2.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload D2.1

Drop files here or

Max. file size: 100 MB.

Rates Upload D2.2

Drop files here or

Max. file size: 100 MB.

Rates Upload D2.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Dental Insurance Plan? D2*

Yes

No

Save and Continue Later

Dental Insurance Additional Plan
Please complete the form and renewal 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.

Dental Carrier 3M

Is this a New Dental Carrier? D3

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Dental Insurance Renewal Date 3M
MM slash DD slash YYYY

Dental Plan Name D3

Dental Plan Type D3
Dental Plan Type: Other D3
Enter the Dental Plan Type

Plan Identifier D3

Group Number D3

COBRA Sub or Account Structure (if applicable) D3

Is this a new Dental Insurance Plan? D3.1

Yes

No
Is this a new Dental Insurance Plan? D3.2

Yes

No

Has the Enrollment Carrier Contact Changed? D3

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name D3.1
First Last
Enrollment Carrier Contact Name D3.2
First Last
Enrollment Carrier Contact Email D3.1

Enrollment Carrier Contact Email D3.2

Enrollment Carrier Contact Phone D3.1
Enrollment Carrier Contact Phone D3.2

Have the Rates changed? D3

Yes

No

Rate Type D3.1
Rate Type D3.2
Rate Type D3.3
Rate Type: Other D3.1
Enter the Rate Type

Rate Type: Other D3.2
Enter the Rate Type

Rate Type: Other D3.3
Enter the Rate Type

Composite Rates D3.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates D3.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates D3.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload D3.1

Drop files here or

Max. file size: 100 MB.

Rates Upload D3.2

Drop files here or

Max. file size: 100 MB.

Rates Upload D3.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Dental Insurance Plan? D3*

Yes

No

Save and Continue Later

Dental Insurance Additional Plan
Please complete the form and renewal 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.

Dental Carrier 4M

Is this a New Dental Carrier? D4

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Dental Insurance Renewal Date 4M
MM slash DD slash YYYY

Dental Plan Name D4

Dental Plan Type D4
Dental Plan Type: Other D4
Enter the Dental Plan Type

Plan Identifier D4

Group Number D4

COBRA Sub or Account Structure (if applicable) D4

Is this a new Dental Insurance Plan? D4.1

Yes

No
Is this a new Dental Insurance Plan? D4.2

Yes

No

Has the Enrollment Carrier Contact Changed? D4

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name D4.1
First Last
Enrollment Carrier Contact Name D4.2
First Last
Enrollment Carrier Contact Email D4.1

Enrollment Carrier Contact Email D4.2

Enrollment Carrier Contact Phone D4.1
Enrollment Carrier Contact Phone D4.2

Have the Rates changed? D4

Yes

No

Rate Type D4.1
Rate Type D4.2
Rate Type D4.3
Rate Type: Other D4.1
Enter the Rate Type

Rate Type: Other D4.2
Enter the Rate Type

Rate Type: Other D4.3
Enter the Rate Type

Composite Rates D4.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates D4.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates D4.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload D4.1

Drop files here or

Max. file size: 100 MB.

Rates Upload D4.2

Drop files here or

Max. file size: 100 MB.

Rates Upload D4.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Dental Insurance Plan? D4*

Yes

No

Save and Continue Later

Dental Insurance Additional Plan
Please complete the form and renewal 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.

Dental Carrier 5M

Is this a New Dental Carrier? D5

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Dental Insurance Renewal Date 5M
MM slash DD slash YYYY

Dental Plan Name D5

Dental Plan Type D5
Dental Plan Type: Other D5
Enter the Dental Plan Type

Plan Identifier D5

Group Number D5

COBRA Sub or Account Structure (if applicable) D5

Is this a new Dental Insurance Plan? D5.1

Yes

No
Is this a new Dental Insurance Plan? D5.2

Yes

No

Has the Enrollment Carrier Contact Changed? D5

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name D5.1
First Last
Enrollment Carrier Contact Name D5.2
First Last
Enrollment Carrier Contact Email D5.1

Enrollment Carrier Contact Email D5.2

Enrollment Carrier Contact Phone D5.1
Enrollment Carrier Contact Phone D5.2

Have the Rates changed? D5

Yes

No

Rate Type D5.1
Rate Type D5.2
Rate Type D5.3
Rate Type: Other D5.1
Enter the Rate Type

Rate Type: Other D5.2
Enter the Rate Type

Rate Type: Other D5.3
Enter the Rate Type

Composite Rates D5.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates D5.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates D5.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload D5.1

Drop files here or

Max. file size: 100 MB.

Rates Upload D5.2

Drop files here or

Max. file size: 100 MB.

Rates Upload D5.3

Drop files here or

Max. file size: 100 MB.

Save and Continue Later

Vision Renewal Details
Please complete the form and renewal 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.

Vision Carrier V1

Is this a New Vision Carrier? V1

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Vision Insurance Renewal Date V1
MM slash DD slash YYYY

Vision Plan Name V1

Vision Plan Type V1
Vision Plan Type: Other V1
Enter the Vision Plan Type

Plan Identifier V1

Group Number V1

COBRA Sub or Account Structure (if applicable) V1

Is this a new Vision Insurance Plan? V1

Yes

No

Have any of the below changed? V1
Note: The Carrier Contact is the individual at the carrier to whom you send Enrollments
Benefit Termination Date
Enrollment Carrier Contact
Plan Funding
Rates
None of these have changed

Benefit Termination Date V1
Benefit Termination Date: Other V1

Enter the benefit termination date

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name V1
First Last
Enrollment Carrier Contact Email V1

Enrollment Carrier Contact Phone V1

Plan Funding V1

Rate Type V1
Rate Type: Other V1
Enter the Rate Type

Composite Rates V1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Upload the Rates by using the below

Rates Upload V1

Drop files here or

Max. file size: 100 MB.

Would you like to add another Vision Insurance Plan? V1*

Yes

No

Save and Continue Later

Vision Insurance: Multiple Plan Details
Please complete the form and renewal 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.

Do all of your Vision Insurance Plans share the same Vision Insurance Carrier?

Yes

No

Do all of you Vision Insurance Plans share the same Renewal Date?

Yes

No

Save and Continue Later

Vision Insurance Additional Plan
Please complete the form and renewal 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.

Vision Carrier V2

Is this a New Vision Carrier? V2

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Vision Insurance Renewal Date V2
MM slash DD slash YYYY

Vision Plan Name V2

Vision Plan Type V2
Vision Plan Type: Other V2
Enter the Dental Plan Type

Plan Identifier V2

Group Number V2

COBRA Sub or Account Structure (if applicable) V2

Is this a new Vision Insurance Plan? V2.1

Yes

No
Is this a new Vision Insurance Plan? V2.2

Yes

No

Has the Enrollment Carrier Contact Changed? V2

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name V2.1
First Last
Enrollment Carrier Contact Name V2.2
First Last
Enrollment Carrier Contact Email V2.1

Enrollment Carrier Contact Email V2.2

Enrollment Carrier Contact Phone V2.1
Enrollment Carrier Contact Phone V2.2

Have the Rates changed? V2

Yes

No

Rate Type V2.1
Rate Type V2.2
Rate Type V2.3
Rate Type: Other V2.1
Enter the Rate Type

Rate Type: Other V2.2
Enter the Rate Type

Rate Type: Other V2.3
Enter the Rate Type

Composite Rates V2.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates V2.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates V2.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload V2.1

Drop files here or

Max. file size: 100 MB.

Rates Upload V2.2

Drop files here or

Max. file size: 100 MB.

Rates Upload V2.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Vision Insurance Plan? V2*

Yes

No

Save and Continue Later

Vision Insurance Additional Plan
Please complete the form and renewal 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.

Vision Carrier V3

Is this a New Vision Carrier? V3

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Vision Insurance Renewal Date V3
MM slash DD slash YYYY

Vision Plan Name V3

Vision Plan Type V3
Vision Plan Type: Other V3
Enter the Dental Plan Type

Plan Identifier V3

Group Number V3

COBRA Sub or Account Structure (if applicable) V3

Is this a new Vision Insurance Plan? V3.1

Yes

No
Is this a new Vision Insurance Plan? V3.2

Yes

No

Has the Enrollment Carrier Contact Changed? V3

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name V3.1
First Last
Enrollment Carrier Contact Name V3.2
First Last
Enrollment Carrier Contact Email V3.1

Enrollment Carrier Contact Email V3.2

Enrollment Carrier Contact Phone V3.1
Enrollment Carrier Contact Phone V3.2

Have the Rates changed? V3

Yes

No

Rate Type V3.1
Rate Type V3.2
Rate Type V3.3
Rate Type: Other V3.1
Enter the Rate Type

Rate Type: Other V3.2
Enter the Rate Type

Rate Type: Other V3.3
Enter the Rate Type

Composite Rates V3.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates V3.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates V3.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload V3.1

Drop files here or

Max. file size: 100 MB.

Rates Upload V3.2

Drop files here or

Max. file size: 100 MB.

Rates Upload V3.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Vision Insurance Plan? V3*

Yes

No

Save and Continue Later

Vision Insurance Additional Plan
Please complete the form and renewal 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.

Vision Carrier V4

Is this a New Vision Carrier? V4

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Vision Insurance Renewal Date V4
MM slash DD slash YYYY

Vision Plan Name V4

Vision Plan Type V4
Vision Plan Type: Other V4
Enter the Dental Plan Type

Plan Identifier V4

Group Number V4

COBRA Sub or Account Structure (if applicable) V4

Is this a new Vision Insurance Plan? V4.1

Yes

No
Is this a new Vision Insurance Plan? V4.2

Yes

No

Has the Enrollment Carrier Contact Changed? V4

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name V4.1
First Last
Enrollment Carrier Contact Name V4.2
First Last
Enrollment Carrier Contact Email V4.1

Enrollment Carrier Contact Email V4.2

Enrollment Carrier Contact Phone V4.1
Enrollment Carrier Contact Phone V4.2

Have the Rates changed? V4

Yes

No

Rate Type V4.1
Rate Type V4.2
Rate Type V4.3
Rate Type: Other V4.1
Enter the Rate Type

Rate Type: Other V4.2
Enter the Rate Type

Rate Type: Other V4.3
Enter the Rate Type

Composite Rates V4.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates V4.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates V4.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload V4.1

Drop files here or

Max. file size: 100 MB.

Rates Upload V4.2

Drop files here or

Max. file size: 100 MB.

Rates Upload V4.3

Drop files here or

Max. file size: 100 MB.

Would you like to add another Vision Insurance Plan? V4*

Yes

No

Save and Continue Later

Vision Insurance Additional Plan
Please complete the form and renewal 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.

Vision Carrier V5

Is this a New Vision Carrier? V5

Yes

No
Please contact the carrier and ask them how to add Admin America Inc as an Authorized Contact.

Vision Insurance Renewal Date V5
MM slash DD slash YYYY

Vision Plan Name V5

Vision Plan Type V5
Vision Plan Type: Other V5
Enter the Dental Plan Type

Plan Identifier V5

Group Number V5

COBRA Sub or Account Structure (if applicable) V5

Is this a new Vision Insurance Plan? V5.1

Yes

No
Is this a new Vision Insurance Plan? V5.2

Yes

No

Has the Enrollment Carrier Contact Changed? V5

Yes

No

The Carrier Contact is the individual at the carrier to whom you send Enrollments

The Carrier Contact is the individual at the carrier to whom you send Enrollments

Enrollment Carrier Contact Name V5.1
First Last
Enrollment Carrier Contact Name V5.2
First Last
Enrollment Carrier Contact Email V5.1

Enrollment Carrier Contact Email V5.2

Enrollment Carrier Contact Phone V5.1
Enrollment Carrier Contact Phone V5.2

Have the Rates changed? V5

Yes

No

Rate Type V5.1
Rate Type V5.2
Rate Type V5.3
Rate Type: Other V5.1
Enter the Rate Type

Rate Type: Other V5.2
Enter the Rate Type

Rate Type: Other V5.3
Enter the Rate Type

Composite Rates V5.1
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates V5.2
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Composite Rates V5.3
Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $685.00

Tier Level Rate

Rates Upload V5.1

Drop files here or

Max. file size: 100 MB.

Rates Upload V5.2

Drop files here or

Max. file size: 100 MB.

Rates Upload V5.3

Drop files here or

Max. file size: 100 MB.

Save and Continue Later

Medical Flexible Spending Account
Please complete the form and renewal 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.

Participants who have a positive FSA Balance as of their Qualifying Event Date will be eligible to elect the FSA Benefit in COBRA for the duration of their current FSA plan year

Does Admin America administer the Medical FSA?

Yes

No

Please provide the following information for your administrator:

FSA Administrator Name

FSA Administrator Group ID / Group Code

FSA Plan Year Start Date
MM slash DD slash YYYY

FSA Plan Year End Date
MM slash DD slash YYYY

FSA Administrator Contact Name
First Last
FSA Administrator Contact Email

FSA Administrator Contact Phone

Save and Continue Later

Health Reimbursement Arrangement
Please complete the form and renewal 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.

Does Admin America administer the HRA?

Yes

No

Admin America will calculate the applicable COBRA fee for the HRA plan.

Please provide the following information for your administrator:

HRA Administrator Name

HRA Administrator Group ID / Group Code

HRA Plan Year Start Date
MM slash DD slash YYYY

HRA Plan Year End Date
MM slash DD slash YYYY

HRA Administrator Contact Name
First Last
HRA Administrator Contact Email

HRA Administrator Contact Phone

HRA Enrollment Process

Automatic enrollment in the HRA when an HRA-eligible plan is elected

HRA election required when an HRA-eligible plan is elected

Are all of your renewing medical insurance plans HRA-eligible?

Yes

No
List the HRA-Eligible Medical Insurance Plans
To add additional plans select +, to remove plans select -
HRA Eligible Plan(s)

HRA COBRA Premiums
Do not include the 2% Admin Fee

Click + to Add a Tier Level and Rate row
Click - to Remove a Tier Level and Rate row

Tier Level example: Family
Rate example: $115.00

Tier Level Rate

Save and Continue Later

Submission Summary
{all_fields}

Save and Continue Later

Renewal Agreement
Please complete the form and renewal 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 renewal purposes.

Your Name*

By entering your name below you are electronically signing this form and agreeing to the above notice.
Your Email*

Date*
MM slash DD slash YYYY

Save and Continue Later

Plan 1	Plan 2	Plan 3	Plan 4	Plan 5	Plan 6	Plan 7	Plan 8	Plan 9	Plan 10

Questions

8:30 am – 5:00 pm EST

Admin America, Inc.

770-992-5959 800-366-2961

Employer Name

Contact Details

Renewal Details

Admin America Inc Assisted Open Enrollment Requirement

Medical Renewal Details

Medical Insurance: Multiple Plan Details

Medical Insurance Additional Plan

Medical Insurance Additional Plan

Medical Insurance Additional Plan

Medical Insurance Additional Plan

Medical Insurance Additional Plan

Medical Insurance Additional Plan

Medical Insurance Additional Plan

Medical Insurance Additional Plan

Medical Insurance Additional Plan

Dental Renewal Details

Dental Insurance: Multiple Plan Details

Dental Insurance Additional Plan

Dental Insurance Additional Plan

Dental Insurance Additional Plan

Dental Insurance Additional Plan

Vision Renewal Details

Vision Insurance: Multiple Plan Details

Vision Insurance Additional Plan

Vision Insurance Additional Plan

Vision Insurance Additional Plan

Vision Insurance Additional Plan

Medical Flexible Spending Account

Health Reimbursement Arrangement

Submission Summary

Renewal Agreement