Business Intake Form
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Preferred Mode of Contact
Services of interest:
Current Coverage Offering(s)
Domestic Partner
Full-Time Student
ER Contributions
Premium Only Plan?
Full Flex?
COBRA/State Continuation?
Quoting Requirements
Takeover Broker of Record
Std/Ltd/Life Quotes
ACA/ERISA EVALUATION
This optional evaluation will help you quickly know whether you are in compliance with ACA, ERISA and/or COBRA which could save you from expensive fines and legal situations.  
Are you sending General Notice/Initial COBRA Notice?
Are you sending General Election Notice?
Are you sending mailings to dependents with different home addresses?
Do you have records of mailings?
FINES: DOL fines for not administering COBRA correctly are $110/day for EACH day the company has been administering incorrectly and out of compliances. Typical fines are the total cost of benefits (medical, dental, vision, disability, life, etc.) for the preceding year divided by 2.
Section 125 Premium Only
Do you have Formal Plan Documents on file?
Have Formal Plan Documents been updated in the past 2 years - ACA?
Is Premium Only plan voluntary or mandatory?
If voluntary, do you have Salary Redirection Agreements for each employee?
Are Salary Redirection Agreements updated each open enrollment period?
FINES: Failure to have proper Section 125 Premium Only Plan Document in place could lead to the following: all pre-tax deductions may be disallowed back to the beginning, IRS assessment of unpaid back taxes plus interest and penalties, possible DAILY DOL fines
Medicare Creditable Drug Coverage Notification
Is notification being provided to employees?
Is disclosure to Centers for Medicare and Medicaid taking place?
FINES: At this time there are no employer fines associated with not providing to employees and/or not registering the prescription drug coverage online with the Centers for Medicare and Medicaid. 
Summary of Benefits & Coverage (SBC) - ACA
Are SBC's provided to employees prior to the coverage effective date?
Are SBC's being mailed to dependents not living at home address of employee?
FINES: for not providing SBC's is $1,000/employee enrolled on the plan and an excise tax of $100/day for each day the document has not been handed out to each employee
Health Exchange Notification - ACA
Is each new hire (Full-Time & Part-Time) being provided a Health Exchange notification?
Are the Health Exchange notifications being updated annually?
FINES: at this time there are no employer fines associated with not providing the State Exchange Notice
Women's Health & Cancer Rights Notice (WHCR) - ERISA
Is the WHCR being provided to employees when initially enrolled on the medical plan?
Is the WHCR Notice being provided annually at open enrollment?
FINES: Employees not receiving the Women's Health & Cancer Rights Notice can sue their employer for not providing the notice.
Children's Health Insurance Program (CHIP) - ERISA
Is CHIP being provided to employees prior to enrolling on the medical plan?
FINES: Employees not receiving the CHIP Notice can sue their employer for not providing the notice.
Summary Plan Document Description (SPD) - ERISA
Do you have formal plan documents on file?
Have SPD documents been updated every year there has been a change in medical coverage?
Are SPD documents being provided to employees at time of initial enrollment or open enrollment if there is a change in medial insurance provider?
FINES: Employees not receiving the Summary Plan Description can sue their employer for not providing the notice.
W2 Reporting Employer Sponsored Coverage - ACA (2015)
Does employer generate 250+ W2's per year?
If yes, is employer including the cost of the medical coverage on the W2's (box DD)?
FINES: failure to do include cost of medical coverage on employee W2's start at $30 per W2 up to a maximum of $1.5 million per calendar year.
Current Coverage
(primary & secondary medical, dental, vision, life, short-term & long-term disability, accident, supplemental, 401k/pension, general liability and/or any voluntary benefits)
If you would like the most accurate information from us, please provide the following information for your current coverage:
             Renewal Date | Carrier Name  |  Plan Design  |  Years w/ Carrier   
COBRA