Employer Information
Company Name:
Street Address:
City:
State:	Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Zip Code:
e-mail address:
Who Referred You:
Employer is a: Corporation Partnership Sole Proprietorship Other   Explain:
Company Contact Person:
Contact Phone Number:	-  -
Contact Fax Number:	-  -
Date business was established:
Type of Business:
Employee Eligibility
Total Number of Employees:
Number of eligible full-time employees(min 30hrs. week):
Are part-time employees(20-29hrs. week) to be covered?  Yes  No
Are all eligible employees subject to federal withholdings on a w-2?  Yes  No
Total number of eligible ENROLLING employees:
Number of eligible employees DECLINING coverage:
Number of INELIGIBLE employees: Reason for ineligibility:
Do you wish to offer coverage for "Domestic Partners"?  Yes  No
Coverage Information
Probationary(waiting) period for new employees:
Requested Effective Date:
Is your group subject to COBRA? (20 or more employees working 50% of the calander year):  Yes  No
Is your group subject to Cal-COBRA coverage? (2-19 full-time employees working 50% of the calander year):  Yes  No
Is your group subject to the Family Medical Leave Act of 1993? (50, or more, total employees):  Yes  No
Current Carrier
Is this plan intended to replace existing group Health coverage?  Yes  No	Name of Group Health Carrier:
Is this plan intened to replace existing group Dental coverage?  Yes  No	Name of Group Medical Carrier:
Health Termination Date:	Dental Termiation Date:
Current worker's compensation carrier:  Policy Renewal Date: