HealthPass/OCA POP New Client Application

Client Application

HealthPass and OCA are pleased to offer an integrated solution for Section 125 Premium Only Plan (POP) documents. This application gathers certain data required to implement your POP plan. Once completed, OCA's implementation team will contact those listed in this application to finalize your implementation.

Application Requirements
- Company Contact Information
- Plan Start Date(s)
- Employee Eligibility Requirements
Please identify your role:*

I am the EmployerI am the Broker

Company Demographics

To apply for services please complete all questions.
Company Name*
Federal Tax-ID*
Organizational Type:*
Employer Address*

Street Address

Street Address Line 2

City State

Zip Code
Does this group have any affiliate employers?*

NoYes
Affiliate Employer Name(s): *

Employer/Broker Contact Information
Primary Contact Name*

First Name Last Name
Primary Contact E-mail*
Phone Number
Please enter a valid phone number.
Is the primary contact an authorized signer for plan documents?*

YesNo
Signatory Contact Name*

First Name Last Name
Signatory Contact E-mail*
example@example.com
Broker Contact

First Name Last Name
Broker Agency/Firm Name
General Agent Name
Broker E-mail
example@example.com
Broker Phone Number

Upon submission of this application, OCA's implementation team will be emailing the contacts provided on this form. The email will provide the necessary parties with additional content and guides to finalize the installation of the benefits.

Should you have any questions or need any additional information, please email your OCA Sales Manager directly or email sales@oca125.com. You may also call OCA at 855-622-0777.

We thank you for the opportunity to be of service!
Name of individual submitting application*

First Name Last Name
Submitters Email*
example@example.com
Title*
Your Signature

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