Step 1 of 10 10% ACA Service YearSelect the calendar year for which coverage data is being reported*Select2015201620172018201920202021202220232024202520262027202820292030 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 DetailsEmployer Legal Name*FEIN*Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Contact DetailsEmployer Contact Name First Last Employer Contact Email Employer Contact PhoneBroker Contact Name First Last Broker Contact Email Broker Contact Phone 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?SelectYesNoUnknownAdmin America, Inc. will help you make this determinationDoes Company have common ownership with other entities?SelectYesNoAn 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 neededWas group health insurance offered during any month of plan year?*SelectYesNoList 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?Select1/12/13/14/15/16/17/18/19/110/111/112/1 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?*SelectFully InsuredSelf-FundedUnknownAdmin America, Inc. will help you make this determinationWas a Medical Plan Option offered that meets the ACA's minimum value standard?*SelectYesNoUnknownAdmin America, Inc. will help you make this determinationWhat was the required monthly employee contribution for the lowest cost minimum value coverage option?*Enter currency format 9,999.99 without the dollar signWhat was the Waiting Period required for Medical benefit eligibility?*Select0 days30 days60 daysOtherExplain the Waiting Period for Medical benefit eligibility*What was your Medical benefit coverage start date?*First of month after waiting periodSame day waiting period is overWhat was your Medical benefit coverage end date after Termination?*SelectEnd of MonthDate of TermList 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?*SelectFully InsuredSelf-FundedUnknownAdmin America, Inc. will help you make this determinationWas a Medical Plan Option offered that met the ACA's minimum value standard?*SelectYesNoUnknownAdmin America, Inc. will help you make this determinationWhat was the required monthly employee contribution for the lowest cost minimum value coverage option?*Enter currency format 9,999.99 without the dollar signWhat was the Waiting Period required for Medical benefit eligibility?*Select0 days30 days60 daysOtherExplain the Waiting Period for Medical benefit eligibility*What was your Medical benefit coverage start date?*First of month after waiting periodSame day waiting period is overWhat was your Medical benefit coverage end date after Termination?*SelectEnd of MonthDate of TermList 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?*SelectFully InsuredSelf-FundedUnknownAdmin America, Inc. will help you make this determinationWas a Medical Plan Option offered that met the ACA's minimum value standard?*SelectYesNoUnknownAdmin America, Inc. will help you make this determinationWhat was the required monthly employee contribution for the lowest cost minimum value coverage option?*Enter currency format 9,999.99 without the dollar signWhat was the Waiting Period required for Medical benefit eligibility?*Select0 days30 days60 daysOtherExplain the Waiting Period for Medical benefit eligibility*What was your Medical benefit coverage start date?*First of month after waiting periodSame day waiting period is overWhat was your Medical benefit coverage end date after Termination?*SelectEnd of MonthDate of TermList any classes of employees excluded from Medical benefit eligibility below (i.e. part-time) or enter NONE* Submission Summary{all_fields} 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.
