NEW Carrier/Plan Renewal

Carrier/Plan Renewal
Company Contact Information
Contact Name*

First NameLast Name
Contact Email*
The person entering this form
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Enter the number of eligible employees*
Open Enrollment

All COBRA participants are required to be notified of their rights under open enrollment. In addition to the plan renewal, AccrueCMS can mail open enrollment packets to all pending and enrolled COBRA participants. Please note there is a $20 per packet charge if you choose this optional service. A mailing list for all participants can be provided upon request at no extra cost.
YesNo
If you answered Yes to Open Enrollment, please upload the documents to be included in the packet.

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Open Enrollment Begin Date

MonthDayYear
Date
Open Enrollment End Date

MonthDayYear
Date
Plan Information
IMPORTANT: If you are also using an HR/Payroll Benefits service that utilizes an Electronic Data Interface (EDI) to share COBRA activity with AccrueCMS, it is very important to enter the Plan Names below exactly as they are listed in the benefits platform that you also use. The spelling should be the same in both systems, so that we can match them accordingly during the EDI process.
NOTICE: AccrueCMS is requesting review of all COBRA Eligibility contacts with your respective carrier contacts.

It is important that we have the correct COBRA Eligibility contacts and are approved as the Third Party Administrator to provide COBRA eligibility on your behalf. We are not responsible for any delay or discrepancies if we do not have the most accurate information.
Up to 8 plans can be entered. Select the plan below, and enter the required information after the data fields are displayed. You must enter at least one plan.

Also be aware that Plan Names cannot exceed 50 characters including spaces.

Carrier Name 1*
Entity Name
Carrier Contact 1*
Email or Fax
Group Number 1*
If you don't have the Carrier Contact and/or Group Number due to a carrier change, please enter "Not Available Yet" in the required data fields above.
Plan Name 1*
Rate Start Date 1*

MonthDayYear
Date
End of MonthDate of Event
YesNo

Plan Coverages 1

Rows	Base Rate (without 2%)
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Employee + 1

If this plan uses age banding and/or requires more options than is included on the coverage table above, you can upload any supporting documents and/or files to assist with the rate/coverages using the browse files button below.
Upload File

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pdf, doc, docx, xls, xlsx, csv, txt, zip, jpg, jpeg, png, gif Cancelof
Additional Comments 1

Carrier Name 2
Entity Name
Carrier Contact 2
Email or Fax
Group Number 2
If you don't have the Carrier Contact and/or Group Number due to a carrier change, please enter "Not Available Yet" in the required data fields above.
Plan Name 2
Rate Start Date 2

MonthDayYear
Date
End of MonthDate of Event
YesNo

Plan Coverages 2

Rows	Base Rate (without 2%)
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Employee + 1

If this plan uses age banding and/or requires more options than is included on the coverage table above, you can upload any supporting documents and/or files to assist with the rate/coverages using the browse files button below.
Upload File

Browse Files
pdf, doc, docx, xls, xlsx, csv, txt, zip, jpg, jpeg, png, gif Cancelof
Additional Comments 2

Carrier Name 3
Entity Name
Carrier Contact 3
Email or Fax
Group Number 3
If you don't have the Carrier Contact and/or Group Number due to a carrier change, please enter "Not Available Yet" in the required data fields above.
Plan Name 3
Rate Start Date 3

MonthDayYear
Date
End of MonthDate of Event
YesNo

Plan Coverages 3

Rows	Base Rate (without 2%)
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Employee + 1

If this plan uses age banding and/or requires more options than is included on the coverage table above, you can upload any supporting documents and/or files to assist with the rate/coverages using the browse files button below.
Upload File

Browse Files
pdf, doc, docx, xls, xlsx, csv, txt, zip, jpg, jpeg, png, gif Cancelof
Additional Comments 3

Carrier Name 4
Entity Name
Carrier Contact 4
Email or Fax
Group Number 4
If you don't have the Carrier Contact and/or Group Number due to a carrier change, please enter "Not Available Yet" in the required data fields above.
Plan Name 4
Rate Start Date 4

MonthDayYear
Date
End of MonthDate of Event
YesNo

Plan Coverages 4

Rows	Base Rate (without 2%)
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Employee + 1

If this plan uses age banding and/or requires more options than is included on the coverage table above, you can upload any supporting documents and/or files to assist with the rate/coverages using the browse files button below.
Upload File

Browse Files
pdf, doc, docx, xls, xlsx, csv, txt, zip, jpg, jpeg, png, gif Cancelof
Additional Comments 4

Carrier Name 5
Entity Name
Carrier Contact 5
Email or Fax
Group Number 5
If you don't have the Carrier Contact and/or Group Number due to a carrier change, please enter "Not Available Yet" in the required data fields above.
Plan Name 5
Rate Start Date 5

MonthDayYear
Date
End of MonthDate of Event
YesNo

Plan Coverages 5

Rows	Base Rate (without 2%)
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Employee + 1

If this plan uses age banding and/or requires more options than is included on the coverage table above, you can upload any supporting documents and/or files to assist with the rate/coverages using the browse files button below.
Upload File 5

Browse Files
pdf, doc, docx, xls, xlsx, csv, txt, zip, jpg, jpeg, png, gif Cancelof
Additional Comments 5

Carrier Name 6
Entity Name
Carrier Contact 6
Email or Fax
Group Number 6
If you don't have the Carrier Contact and/or Group Number due to a carrier change, please enter "Not Available Yet" in the required data fields above.
Plan Name 6
Rate Start Date 6

MonthDayYear
Date
End of MonthDate of Event
YesNo

Plan Coverages 6

Rows	Base Rate (without 2%)
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Employee + 1

If this plan uses age banding and/or requires more options than is included on the coverage table above, you can upload any supporting documents and/or files to assist with the rate/coverages using the browse files button below.
Upload File 6

Browse Files
pdf, doc, docx, xls, xlsx, csv, txt, zip, jpg, jpeg, png, gif Cancelof
Additional Comments 6

Carrier Name 7
Entity Name
Carrier Contact 7
Email or Fax
Group Number 7
If you don't have the Carrier Contact and/or Group Number due to a carrier change, please enter "Not Available Yet" in the required data fields above.
Plan Name 7
Rate Start Date 7

MonthDayYear
Date
End of MonthDate of Event
YesNo

Plan Coverages 7

Rows	Base Rate (without 2%)
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Employee + 1

If this plan uses age banding and/or requires more options than is included on the coverage table above, you can upload any supporting documents and/or files to assist with the rate/coverages using the browse files button below.
Upload File 7

Browse Files
pdf, doc, docx, xls, xlsx, csv, txt, zip, jpg, jpeg, png, gif Cancelof
Additional Comments 7

Carrier Name 8
Entity Name
Carrier Contact 8
Email or Fax
Group Number 8
If you don't have the Carrier Contact and/or Group Number due to a carrier change, please enter "Not Available Yet" in the required data fields above.
Plan Name 8
Rate Start Date 8

MonthDayYear
Date
End of MonthDate of Event
YesNo

Plan Coverages 8

Rows	Base Rate (without 2%)
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Employee + 1

If this plan uses age banding and/or requires more options than is included on the coverage table above, you can upload any supporting documents and/or files to assist with the rate/coverages using the browse files button below.
Upload File 8

Browse Files
pdf, doc, docx, xls, xlsx, csv, txt, zip, jpg, jpeg, png, gif Cancelof
Additional Comments 8

Carrier/Plan Renewal

Company Contact Information

Open Enrollment

Plan Information