OCAs POP New Client Application

Client Application

Premium Only Plan (POP) - Is one of the simplest benefits an employer can offer, and it delivers real savings to employees and their company. By allowing employees to pay their portion of premium costs BEFORE taxes, employees typically save 25% or more and the employer benefits from nearly 8% in FICA savings. However, to deduct employee premium costs pretax, you MUST have a plan document. By taking advantage of Section 125 of the Internal Revenue Code, employers can save money for their employees and themselves.

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

CityState

Zip Code
Does this group have any adopting employers?*

NoYes
Adopting Employer Name(s): *

Employer/Broker Contact Information
Primary Contact Name

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

First NameLast 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!
Please identify your OCA Sales Representative*
Name of individual submitting application*

First NameLast Name
Title*
Your Signature*

Clear
Submission Type

POP
Should be Empty: