ACA Service Enrollment Application

Submission of this Enrollment Application reserves Employer access to Admin America's {For which year are you requesting ACA services?:98} ACA Reporting Service. A 50% deposit is due at the time of enrollment, according to the Full-time count provided, and the remainder of the fee will be billed upon approval of the 1095 form drafts.
Employer Details
Employer Legal Name*
FEIN*
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employer Status Details
All questions below pertain to year {For which year are you requesting ACA services?:98}
Estimated number of Unique Full-time/Equivalent employed 130 hours during any month of year*
Was Company an Applicable Large Employer (ALE) for ACA Purposes?
Admin America, Inc. will help you make this determination
Does Company have common ownership with other entities?
An ACA Service Enrollment Application is required for each entity for which you want {For which year are you requesting ACA services?:98} ACA services.

A link to submit an additional form will be available after submission of the form you are currently completing.
List the FEIN of each entity that will require ACA services

Click the + add rows and the - to remove rows as needed
Was group health insurance offered during any month of plan year?*
List any classes of employees excluded from benefit eligibility below (i.e. part-time) or enter NONE

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?

Employer ACA Data Information for 1/1 Renewal
All questions below pertain to your Medical Plan(s) for renewal date {What is the Renewal Date of your Medical Plan?:28}/{For which year are you requesting ACA services?:98}
Was your Medical Plan Fully Insured or Self-Funded?*
Admin America, Inc. will help you make this determination
Was a Medical Plan Option offered that meets the ACA's minimum value standard?*
Did you offer an ICHRA (Individual Coverage Health Reimbursment Account)?*
Admin America, Inc. will help you make this determination
What was the required monthly employee contribution for the lowest cost minimum value coverage option?*
Enter currency format 9,999.99 without the dollar sign
What was the Waiting Period required for Medical benefit eligibility?*
Explain the Waiting Period for Medical benefit eligibility*
What was your Medical benefit coverage start date?*
- First of month after waiting period
- Same day waiting period is over
What was your Medical benefit coverage end date after Termination?*
List any classes of employees excluded from Medical benefit eligibility below (i.e. part-time) or enter NONE*

Employer ACA Data Information Before Renewal
All questions below pertain to your Medical Plan(s) prior to {What is the Renewal Date of your Medical Plan?:28}/{For which year are you requesting ACA services?:98}
Was your Medical Plan Fully Insured or Self-Funded?*
Admin America, Inc. will help you make this determination
Was a Medical Plan Option offered that met the ACA's minimum value standard?*
Admin America, Inc. will help you make this determination
What was the required monthly employee contribution for the lowest cost minimum value coverage option?*
Enter currency format 9,999.99 without the dollar sign
What was the Waiting Period required for Medical benefit eligibility?*
Explain the Waiting Period for Medical benefit eligibility*
What was your Medical benefit coverage start date?*
- First of month after waiting period
- Same day waiting period is over
What was your Medical benefit coverage end date after Termination?*
List any classes of employees excluded from Medical benefit eligibility below (i.e. part-time) or enter NONE*

Employer ACA Data Information After Renewal
All questions below pertain to your Medical Plan(s) after {What is the Renewal Date of your Medical Plan?:28}/{For which year are you requesting ACA services?:98}
Was your Medical Plan Fully Insured or Self-Funded?*
Admin America, Inc. will help you make this determination
Was a Medical Plan Option offered that met the ACA's minimum value standard?*
Admin America, Inc. will help you make this determination
What was the required monthly employee contribution for the lowest cost minimum value coverage option?*
Enter currency format 9,999.99 without the dollar sign
What was the Waiting Period required for Medical benefit eligibility?*
Explain the Waiting Period for Medical benefit eligibility*
What was your Medical benefit coverage start date?*
- First of month after waiting period
- Same day waiting period is over
What was your Medical benefit coverage end date after Termination?*
List any classes of employees excluded from Medical benefit eligibility below (i.e. part-time) or enter NONE*

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.

Billing Information
ACA Reporting
Price: $750.00
Total
$0.00

Additionally, for each form generated, a $3.50 fee will be invoiced to you.
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
Card Number Expiration Date Security Code Cardholder Name
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ACA Service Year