Technology & Education Onboarding Form
Please note that these items are required in order for PES to move forward with the implementation process. Any delay in receipt of these items may cause a delay in this process. If you began the form but need additional information to complete, please scroll to the bottom of the form and select “Save". If any item is not applicable, please enter “N/A” into the field.
Client or Parent Company Name (dba)
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Respondent Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Today's Date
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-
Month
-
Day
Year
Date
When would you like to begin enrollment?
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Month
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Day
Year
Date
Will you be conducting an Active or Passive enrollment?
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Active
Passive
Please provide business legal name(s), address(es), phone number(s), contact person, and FEINs.
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Are there any additional participating locations than the one entered above?
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Yes
No
Please upload a full list of locations that are participating in this enrollment/service, including their addresses, phone number, contact person and FEINs (as applicable).
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Please upload a copy of the business' W9 (some carriers require this form when quoting out products).
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What is the nature of the business(es)?
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If you require benefit system administrator access, please provide the name, phone number, and email address of those you wish to have access. Please designate if any restrictions for viewing locations, salaries, etc., are needed.
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Will you be utilizing the system for ongoing enrollments?
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Yes
No
Which benefits will you be utilizing the system for?
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Please provide all applicable product offerings for this Open Enrollment (Medical, Dental, Vision, Voluntary, Spending Accounts, etc.), their carriers, and corresponding plan year dates.
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Upload a document with required benefits info
Type out a list of required benefits info
Please list out all applicable product offerings for this Open Enrollment (Medical, Dental, Vision, Voluntary, Spending Accounts, etc.), their carriers, and corresponding plan year dates.
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Please upload all applicable product offering documents for this Open Enrollment (Medical, Dental, Vision, Voluntary, Spending Accounts, etc.), their carriers, and corresponding plan year dates.
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If medical is offered, is it self insured?
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What voluntary benefits are currently offered and with which carrier(s)?
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Type out list of voluntary benefits and applicable carrier(s)
Upload document of voluntary benefits and applicable carrier(s)
Please list all voluntary benefits currently offered and their applicable carrier(s).
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Please upload a document with all voluntary benefits currently offered and their applicable carrier(s).
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Are these voluntary benefits pre-tax or post-tax?
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Pre-tax
Post-tax
Other
If other, please explain.
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Please upload a full EE current coverage report.
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Will an employee’s current coverage roll over/continue if the employee does not elect benefits during the upcoming open enrollment period?
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Yes, the current coverage will continue through the upcoming benefit year
No, all employees must elect new benefits during open enrollment or coverage will terminate
Please provide a list/report of the current coverage that will roll over
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Do you have more than one payroll schedule or deduction frequency?
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Yes
No
What is your payroll schedule and deduction frequency?
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Please detail all payroll schedule and deduction frequencies.
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Please provide the 1st and 2nd pay period end dates and the first check date for the plan year.
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Do employees use/have access to an enrollment platform to sign up for their benefits?
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Yes
No
Which platform is being used (Ease, ENav, PlanSource, ADP, etc)?
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If new products are being offered, will they be build on this platform?
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Yes
No
Who will be administering your COBRA Benefits?
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Will COBRA be managed on the platform?
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Yes
No
Is a spending account (HSA, FSA, etc.) offered?
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Yes
No
Please provide detail on the offered spending account(s) (HSA, FSA, etc.).
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Are employer-paid benefits offered (Employer paid life, LTD, STD)?
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Yes
No
Please provide a list of all employer-paid benefits.
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What is the new hire waiting period?
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Do any benefit start dates differ from the new hire rule?
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Yes
No
Please detail the benefits that have start dates which differ from the new hire rule.
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Are there any rehire effective date rules that differ from new hire rules?
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Yes
No
Please detail the rehire effective date rules that differ from new hire rules.
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When do benefits terminate (end of the month, termination date, etc.)?
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Do all benefits follow the same termination schedule?
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Yes
No
Please detail the benefits that do not follow the termination schedule above, and what their applicable termination schedule(s).
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What are the coverage start/end date rules for status changes (i.e., part-time, to full-time, leave of absence, etc.)?
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Are there any variations on rates or eligibility based on locations, divisions, departments, and/or classes?
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Yes
No
Please detail all variations.
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Do any benefits require minimum hours worked for eligibility?
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Yes
No
If so, please detail.
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Does coverage require student designation for children over age 18?
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Yes
No
For children who turn 26, when does coverage terminate (birth date, end of the month, plan year, etc.)?
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Is this termination rule different for any coverages?
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Yes
No
Please indicate for which benefits this termination rule is different, and their applicable termination rule.
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Are domestic partners eligible?
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Yes
No
Are domestic partner's dependents also eligible?
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Yes
No
Are same-sex spouses eligible?
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Yes
No
Are same-sex spouse's dependents also eligible?
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Yes
No
Do you calculate imputed income for domestic partners or same-sex spouses?
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Yes
No
Is this imputed income on on a pre-tax or post-tax basis?
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Pre-tax
Post-tax
Does the billing need to be broken down by location, FEIN, etc.?
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Yes
No
Are there any specific data return templates needed for payroll or carriers?
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Yes
No
Please upload the applicable data return templates needed for payroll or carriers.
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Please upload a complete employee census (SSN, annual salary, hourly rate, date of birth, gender, full address, email, phone number, employment level, hours per week, union/non-union, location/office, hire date).
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As part of the employee benefits experience, PES would like to offer all of your employees our Free Prescription Discount Card. This card lets employees, their family and their friends save up to 70% on their prescriptions at over 60,000 participating pharmacies across the United States. Everyone is eligible, regardless of benefits coverage. Would you like us to share these cards with your employees? For more information, you can visit www.pesenroll.com/rx.
Yes
No
Please upload any logos that you would like added to communication materials that are sent out to employees (transparent background is best).
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PES offers our clients access to PES Perks, a free perks program that provides exclusive discounts on top brands for travel, electronics, restaurants, auto, apparel and more! Would you like to offer your employees this perk?
Yes
No
Please upload any additional documents here.
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