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  • 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:*

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  • Company Demographics

    To apply for services please complete all questions.
  • Does this group have any affiliate employers?*

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  • Employer/Broker Contact Information

  • Format: (000) 000-0000.
  • Is the primary contact an authorized signer for plan documents?*

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  • Premium Only Plan

  • Are you creating a new POP plan or amending an existing plan?*
  • Original Plan Effective Date*
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  • Plan Amendment Date*
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  • Plan Effective Date*
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  • Benefit(s) To Be Offered in Premium Only Plan*

  • Cash Option (If applicable)

    Does your organization have any of the arrangements mentioned below? If yes, please place a check next to the arrangement(​s) and clearly provide the specific details of the arrangement(s). The specific details of the arrangement(s) are required so they can be incorporated into your Plan Documents and Premium Conversion Election Agreement.

  • Please select which case option you offer:
  • The following class of employees are eligible to participate:*
  • The service period employees must complete before being eligible to participate is as follows:*
  • Once the employees are eligible, they can begin participating in the plan:*
  • Is there any classification of employees participating in the Section 125 Cafeteria Plan that will not have the same service period and eligibility requirements mentioned above (i.e. salaried, hourly, union and non-union)?*

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  • 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!

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