New Client Implementation Form
Company Information
Employer Name
Address
Phone Number
-
Area Code
Phone Number
Fax Number
SIC Code
Tax ID
Corporation Type
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New Client Implementation Form
Contacts Information
Contact Name
Type of Contact
Title
Phone Number
-
Area Code
Phone Number
Email Address
example@example.com
Do you have different payroll cycles for your employees?
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New Client Implementation Form
Class Structure
Classes (i.e. plans with different waiting periods, eligibility, payroll deductions, classes as defined in your benefit contracts)
Departments (Departments may be assigned to employees and, optionally, used as benefit eligibility criteria)
Divisions (Divisions are primarily used for controlling HR access to groups of employees)
Business Units (Business units are commonly used to define organizational units such as multiple companies operating a single set of benefits)
Offices (Offices are primarily used for controlling HR access to groups of employees)
Dynamic Classes (Dynamic classes are a combination of several employee demographic elements into a grouping for easier targeting on enrollment; e.g. Maryland exempt and Maryland non-exempt)
Geographic Areas (ACA rates may vary across geographic areas. They may also vary between carriers. Setup areas that will be used to control rate tables for various ACA-controlled
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Plan/Benefits Information
Carrier Name
Policy Number
Policy Start Date
/
Month
/
Day
Year
Date
Policy End Date
/
Month
/
Day
Year
Date
Dependent covered to age
Plan Rates
Plan Eligibility
Contributions
Carrier Contact Number
-
Area Code
Phone Number
Carrier Website (if desired)
Plan Details
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Employee Census Information (Employee & Dependent)
SSN
Name
First Name
Middle Name
Last Name
Suffix
Gender
Relationship
Date of Birth
/
Month
/
Day
Year
Date
Hire Date
/
Month
/
Day
Year
Date
ACA Classification Eligible (Regularly working more than 30 hours)/Ineligible (Regularly working less than 30 hours)/Variable Hour
Compensation Type (Hourly/Salaried)
Hourly Rate
Annual Base Salary
Address
Address
Street Address Line 2
City
State
Zip
Benefit Plan Elections
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