Decisely ACA Reporting non-ALE

Decisely ACA Reporting Services (non-ALE Employers)

1ACA Service Year
2Employer Details
3Contact Details
4Employer ACA Data Information
5Submission Summary
6Authorized Representative Information
7Billing Information

Company Status*

Current
Company Type*

Client
ACA Service Year
Select the calendar year for which coverage data is being reported*

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Submission of this Enrollment Application reserves Employer access to Admin America’s {For which year are you requesting ACA services?:98} ACA Reporting Service.

Employer Details
Employer Legal Name*

FEIN*

Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Contact Details
Employer Contact Name*
First Last

Employer Contact Title*

Employer Contact Email*

Employer Contact Phone*

Brokerage/Agency

Broker Contact Name
First Last

Broker Contact Email

Broker Contact Phone

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Employer ACA Data Information

The question below pertains to year {For which year are you requesting ACA services?:98}

What is the Renewal Date of your Medical Plan?*

Coverage Type (Pre-Renewal)*

Coverage Type (Post-Renewal)*

Plan Renewal Month*

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Submission Summary
{all_fields}

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Authorized Representative's Email*
The details of your submission will be sent to the email address provided below.

Additional Email(s) (optional)
The details of your submission will be sent to the email address(es) provided below.
To send to multiple email addresses, separate the email addresses with a comma.

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Billing Information

ACA Reporting
Price:
Coupon

Total
$0.00

Billing Contact*
Enter the First and Last Name of the Credit Card Holder as it appears on the Credit Card.
First Last
Billing Contact Email*
The receipt will be sent to the email address entered.

Billing Contact Phone*
Billing Address*
Enter the Address associated with the Credit Card

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

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