• AffinityChoice Logo

    Summary Proposal & Employer Plan Selections

    Program Website: https://www.affinitychoice.net

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  • AffinityChoice is a coordinated package of voluntary benefit coverages for employees and their families, offering Life, Dental, Vision and Disability insurance.  It is developed by Affinity Group Underwriters, Inc. and underwritten by Renaissance Life & Health Insurance Company of America.

    Employers with 10 or more full-time employees may apply. Part-time (less than 30 hours per week), temporary and seasonal employees are excluded. Certain industries are ineligible. There are no minimum percentage participation requirements. No health questions or physical exams are required to qualify.

  • Employers Choose:

    • a fixed monthly amount to be contributed on behalf of each participating employee (minimum $25).
    • the class(es) of employees to be eligible.
    • the Basic Life and Accident insurance amount for which each eligible employee will be covered ($10,000; $20,000; $30,000; 40,000 or $50,000).
    • whether or not Short-term Disability benefits are to be offered.

  • Employees Choose:

    • the types of benefits for which they wish to enroll.
    • the amounts of coverage needed and affordable for themselves and their families.

  • NEXT STEPS

    1. Review the Benefit Descriptions
    2. Choose Your Contribution & Customize Your Plan
    3. Complete the Employer Group Master Application
    4. Submit Application for Approval
    • Hidden Fields 
    • Coverage Types
    • Rule Organizer
    • Mode
    • Class I Calculations 
    • Class II Calculations 
    • Class III Calculations 
    • Summary Tables 
    • WAITING PERIODS (for transfer) 
    • BASIC LIFE & AD&D PREMIUM INCLUDED OR NOT 
    • # of Full-Time Employees 
    • Addresses 

  • Basic Life & AD&D

    All eligible employees are automatically covered for life insurance and a matching amount of accidental death & dismemberment (AD&D) insurance. The employer chooses the amount of basic coverage ($10,000 to $50,000 in $10,000 increments) and pays the entire premium which can be deducted from or added to the defined contribution the employer agrees to make.

    In the event of accidental death, the AD&D benefit is payable in addition to the life insurance benefit. Benefits for dismemberment are a percentage of the accidental death benefit based on the type of injury.

    Basic Life and AD&D benefits are reduced after age 65.

    No Spouse* or dependent children Basic Life & AD&D coverage is available.

    Premiums are age-banded and change when the employee reaches a new age category.

    Benefits terminate upon the employee's retirement or when no longer actively working for the employer.

  • Voluntary Life & AD&D

    Up to $50,000 (in units of $10,000) of additional life insurance coverage (with a matching amount of AD&D) is available for employees on a guaranteed issue basis if applying when first eligible.

    Coverage can also be purchased on a guaranteed issue basis for the employee's Spouse / Domestic Partner*. The maximum Spouse coverage is $25,000 or 50% of the employee's coverage amount, whichever is less. Spouse coverage also includes matching AD&D.

    The benefit option for children is $10,000. There is no AD&D coverage for children.

    In the event of accidental death, the AD&D benefit is payable in addition to the voluntary life insurance benefit. Benefits for dismemberment are a percentage of the accidental death benefit based on the type of injury.

    Voluntary Life and AD&D benefits are reduced after age 65.

    Premiums are age-banded and change when the insured person reaches a new age category.

    Benefits terminate upon the employee's retirement or when no longer actively working full time for the employer.

    *“Spouse / Domestic Partner” means your lawful Spouse and any other person required to be covered as your Spouse by the Policyholder or under the civil union, domestic partnership, marriage or other family or domestic relations laws, including the case law, of any applicable State law.

  • Dental

    Any licensed dentist may be seen for treatment. Dentists participating in the provider network, however, accept the insurance company’s allowance as payment in full. Non-participating dentists may bill the insured for the balance. See program website to find a participating dentist.

    Deductible $100 lifetime per person
    Preventive Services
    e.g. Routine Exams & Cleanings    		 Paid at 100% of allowable charge
    Basic Services
    e.g. Fillings, Extractions & Pain Treatments    		 Paid at 80% of allowable charge
    Major Services
    e.g. Periodontics, Endontics, Crowns, Bridges & Implants    		 Paid at 50% of allowable charge
    12 month waiting period
    Annual Maximum Benefits Per Person $2,000
    Orthodontics For Children Paid at 50% of allowable charge
    12 month waiting period
    Lifetime orthodontia maximum per child - $1,000

  • Vision

    Any licensed vision provider may be used. Going to a participating network provider or retailer, however, can reduce the out-of-pocket cost. See program website to find a participating provider.

    Payment is based on allowable charges in the area where service is rendered.

    Coverage includes:

    • Annual Eye Exams
    • Standard Lenses, once every 12 months (Single Vision, Bifocal & Trifocal)
    • Frames, once every 24 months
    • Contact Lenses, once every 12 months

  • Short Term Disability

    Short term disability is an income replacement plan that pays 60% of income if a covered employee is unable to work due to a covered sickness or accident.

    • Benefits begin after a 15-day waiting period and can continue for up to 26 weeks.
    • Maximum weekly benefit payable is $1,250. 
    • Covers annual income of up to $108,333.
    • Limitation: Pre-existing Conditions* are excluded for short term disability. The pre-existing conditions exclusion does not apply after the insured has been covered for 12 months.
    • Maternity is covered (subject to the pre-existing conditions limitation).

    * a Pre-existing Condition is any Sickness or Injury, whether diagnosed or not, for which:

    • Treatment was received, or
    • where symptoms were present to the degree that an ordinarily prudent person would seek Treatment within the 12 months prior to the insured’s effective date of coverage.

  • Let's Get Started

    What's the name of your company? After that, you can customize your plan choices.
  • Are there subsidiary or affiliate businesses covered under this plan?*
  • Are separate billings required?*
    • Subsidiary #1 
    • Do you wish to add another subsidiary?
    • Subsidiary #2 
    • Do you wish to add another subsidiary?
    • Subsidiary #3 
    • Do you wish to add another subsidiary?
    • Subsidiary #4 

  • Add Eligible Class

    Please answer the questions below to create eligibility requirements for a class of employees. You may create up to three classes. Eligibility is limited to all regular full‐time employees working a minimum of 30 hours per week.
  • Define Class I:*
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  • Are any employees disabled at this time?*
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  • Choose a Waiting Period (in Days):*
  • Waive the Waiting Period for current employees?*
  • Would you like to offer Short-Term Disability?*
  • Choose your Employer Monthly Contribution Amount:*
  • Choose Basic Life and AD&D Coverage Amount for participating employees:*
  • Do you wish to add Basic Life and AD&D premium to your monthly contribution?*

  • Your Monthly Contribution:

    {C1_PRICE}

    per Class I employee

  • Add Eligible Class

    Please answer the questions below to create eligibility requirements for a class of employees. Eligibility limited to all regular full‐time employees working a minimum of 30 hours per week.
  • Define Class II:*
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  • Are any employees disabled at this time?*
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  • Choose a Waiting Period (in Days):*
  • Waive the Waiting Period for current employees?*
  • Would you like to offer Short-Term Disability?*
  • Choose your Employer Monthly Contribution Amount:*
  • Choose Basic Life and AD&D Coverage Amount for participating employees:*
  • Do you wish to add Basic Life and AD&D premium to your monthly contribution?*

  • Your Monthly Contribution:

    {C2_PRICE}

    per Class II employee

    Class I Contribution: {C1_PRICE}

  • Add Eligible Class

    Please answer the questions below to create eligibility requirements for a class of employees. Eligibility limited to all regular full‐time employees working a minimum of 30 hours per week.
  • Define Class III:*
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  • Are any employees disabled at this time?*
  • 0/140
  • Choose a Waiting Period (in Days):*
  • Waive the Waiting Period for current employees?*
  • Would you like to offer Short-Term Disability?*
  • Choose your Employer Monthly Contribution Amount:*
  • Choose Basic Life and AD&D Coverage Amount for participating employees:*
  • Do you wish to add Basic Life and AD&D premium to your monthly contribution?*

  • Your Monthly Contribution:

    {C3_PRICE}

    per Class III employee

    Class I Contribution: {C1_PRICE}
    Class II Contribution: {C2_PRICE}

  • Excluded Employees

  • Are any employees excluded from coverage?*
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  • Plan Summary for {employerName}
    Please review the plan summary for each class you created in the previous steps. You can edit your responses by using the back button at the bottom of the form (don't use the browser's back button).

  • Class I Summary

    Class Definition: {C1_description}
    {C1_eligibleemployees} Eligible Employees
    Disabled Employees: {C1_disabled}
    Waiting Period: {c1_cwp}
    Include Short Term Disability? {C1_offerstdis}
    Basic Life & AD&D: {c1_bladd}
    {c1PremiumInclusion}
    TOTAL MONTHLY
    EMPLOYER CONTRIBUTION:    		 {C1_PRICE}
    per Class I employee per month

  • Class II Summary

    Class Definition: {C2_description}
    {C2_eligibleemployees} Eligible Employees
    Disabled Employees: {C2_disabled}
    Waiting Period: {c2_cwp}
    Include Short Term Disability? {C2_offerstdis}
    Basic Life & AD&D: {c2_bladd}
    {c2PremiumInclusion}
    TOTAL MONTHLY
    EMPLOYER CONTRIBUTION:    		 {C2_PRICE}
    per Class II employee per month

  • Class III Summary

    Class Definition: {C3_description}
    {C3_eligibleemployees} Eligible Employees
    Disabled Employees: {C3_disabled}
    Waiting Period: {c3_cwp}
    Include Short Term Disability? {C3_offerstdis}
    Basic Life & AD&D: {c3_bladd}
    {c3PremiumInclusion}
    TOTAL MONTHLY
    EMPLOYER CONTRIBUTION:    		 {C3_PRICE}
    per Class III employee per month

  • Your Existing insurance

    {existinginsurance_info}

  • Excluded Employees

    {excludedemployees_info}

  • Employer Information

    Please complete the fields below.
  • What type of business is this?*
  • Click here if you are using a mailing address different than above.*
  • Will the requested insurance replace existing insurance?*
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  • Requested Effective Date:*
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  • Contact Information

    Please complete the fields below.
  • Format: (000) 000-0000.
  • Do you wish to add a specific person as an billing contact?*
  • Format: (000) 000-0000.
  • Do you wish to add a specific person as a group admin?*
  • Format: (000) 000-0000.

  • Employee Eligibility Information

    Please complete the fields below.
  • Are benefits extended to Domestic Partners?
  • Definition of Spouse: Your lawful Spouse and any other person required to be covered as Your Spouse by the Policyholder or under the civil union, domestic partnership, marriage or other family or domestic relations laws, including the case law, of any applicable State law.
  • Are retired employees to be included as a class for any benefit?

  • Take Over Benefit(s)

    Please refer to your Summary Proposal & Employer Plan Selections for insurance specifications.
  • Is this coverage replacing any existing group insurance?*

  • Please atach a copy of your most recent bill and policy.

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  • Special Requests or Instructions

    Please refer to your Summary Proposal & Employer Plan Selections for insurance specifications.
  • Do you have any special request or instructions?*
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  • Electronic Delivery of Policy Documents

    Please review and sign below.

  • Policyholder Agreement

  • I UNDERSTAND THAT THE POLICY FOR WHICH I AM APPLYING INCLUDES MINIMUM PARTICIPATION REQUIREMENTS. IF A SUFFICIENT NUMBER OR PERCENTAGE OF ELIGIBLE EMPLOYEES FAIL TO ENROLL AND THE MINIMUM PARTICIPATION REQUIREMENTS FOR ISSUANCE OF THE POLICY ARE NOT MET, THE INSURANCE WILL NOT BECOME EFFECTIVE.

    NOTE THAT THE ABOVE PARAGRAPH DOES NOT APPLY TO AFFINITYCHOICE.

    IF EMPLOYEES ARE PAYING ALL OR A PORTION OF THE PREMIUMS, WE AGREE TO DEDUCT APPLICABLE PREMIUMS FROM THE PAYROLL AND REMIT TO RENAISSANCE ON A MONTHLY BASIS.

    I AGREE TO ACCEPT THE TERMS AND PROVISIONS OF THE POLICY, INCLUDING ITS EXHIBITS, RIDERS, ENDORSEMENTS OR AMENDMENTS, IF ANY. I UNDERSTAND THAT NO INSURANCE IS EFFECTIVE UNTIL AFTER THIS APPLICATION IS ACCEPTED BY RENAISSANCE OR THE EFFECTIVE DATE OF COVERAGE, WHICHEVER IS LATER. I UNDERSTAND THAT NO AGENT OR BROKER MAY CHANGE OR WAIVE ANY OF THE PROVISIONS OF THIS APPLICATION. I FURTHER UNDERSTAND THAT RENAISSANCE MAY NOT BE DESIGNATED AS THE “PLAN ADMINISTRATOR” OR “FIDUCIARY” OF THE EMPLOYEE WELFARE BENEFIT PLAN UNDER ERISA.

    I UNDERSTAND AND AGREE THAT IF AN EMPLOYEE IS NOT ACTIVELY AT WORK ON THE DAY THE EMPLOYEE WOULD NORMALLY BECOME INSURED, THE EMPLOYEE WILL BECOME INSURED ON THE DAY THE EMPLOYEE RETURNS TO ACTIVE WORK, EXCEPT AS OTHERWISE MAY BE PROVIDED IN THE GROUP POLICY(IES).

    I HAVE READ AND UNDERSTAND THIS ENTIRE APPLICATION. THE INFORMATION PROVIDED IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THE INFORMATION ON THIS APPLICATION AND ANY OTHER INFORMATION I PROVIDE SHALL SERVE AS THE BASIS FOR THE INSURANCE TO BE ISSUED. I HAVE A DUTY TO NOTIFY RENAISSANCE OF ANY CHANGES. I FURTHER UNDERSTAND THAT THE BENEFITS PROVIDED BY RENAISSANCE TO MY EMPLOYEES AND THEIR DEPENDENTS ARE BASED ON THE INFORMATION I PROVIDE. I UNDERSTAND THAT IN THE EVENT OF A CONFLICT BETWEEN ANY PROPOSALS PROVIDED AND THE POLICY ISSUED BY RENAISSANCE THE TERMS OF THE POLICY WILL PREVAIL. IT IS UNDERSTOOD AND AGREED THAT THIS APPLICATION SHALL BE MADE A PART OF THE POLICY APPLIED FOR AND THAT NO INSURANCE SHALL BE EFFECTIVE UNTIL APPROVED BY RENAISSANCE AT ITS HOME OFFICE.

    I UNDERSTAND THAT THE TAX CONSEQUENCES TO THE EMPLOYER AND THE EMPLOYEE DEPEND ON A VARIETY OF FACTORS, INCLUDING THE RESPONSES TO THE QUESTIONS SET FORTH IN THIS APPLICATION. I HAVE NOT RELIED ON RENAISSANCE OR ANY OF ITS AGENTS OR EMPLOYEES FOR PURPOSES OF ASSESSING THESE TAX CONSEQUENCES AND AM RELYING EXCLUSIVELY ON MY TAX ADVISOR IN THIS REGARD.

    I UNDERSTAND THAT THE LAWS OF THE STATE OF THE POLICYHOLDER WILL GOVERN THE POLICY. MISREPRESENTATION OF MATERIAL FACT OR FRAUD WILL CAUSE THIS APPLICATION AND SUBSEQUENT POLICY TO BE NULL AND VOID FROM THE START.

    FRAUD WARNING FOR LIFE AND DISABILITY COVERAGES: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW. FRAUD WARNING FOR DENTAL AND VISION COVERAGES: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE OR SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD. (PLEASE SEE THE FOLLOWING PAGE FOR STATE-SPECIFIC VARIATIONS OF THIS FRAUD NOTICE).

    THIS POLICY PROVIDES DENTAL AND/OR VISION BENEFITS. PLEASE REVIEW YOUR POLICY CAREFULLY

    This type of plan is NOT considered “minimum essential coverage” under the Affordable Care Act and therefore does NOT satisfy the individual mandate that you have health insurance coverage. If you do not have other health insurance coverage, you may be subject to a federal tax penalty.

    NOTE FOR COLORADO RESIDENTS: This policy does not include coverage for certain pediatric dental services that may be required under federal law. Coverage of those pediatric dental services, defined as essential health benefits (“EHB”) in accordance with the Affordable Care Act, is available for purchase in the State of Colorado and can be purchased as a stand-alone plan, or as a covered benefit in another health plan. Please contact your insurance agent, or Connect for Health Colorado if you need to purchase an exchange-qualified, stand-alone dental plan that includes pediatric dental coverage.

  • CLAIMS TAX SERVICES

  • Policyholder/Employer is electing Standard Tax Services alone. Renaissance will provide Policyholder/Employer by January 15th of each year the information required by Federal law to enable Policyholder/Employer to produce Form W-2 for its active and terminated employees. Policyholder/Employer is responsible for W-2 production, distribution, and filing in accordance with federal requirements. Policyholder/Employer will report and deposit Employer FICA taxes from disability benefits/sick pay with the appropriate United States federal agencies.

    CHANGING W-2 TAX SERVICE SELECTION

    Policyholder/Employer agrees that any service change regarding Form W-2 must be requested in writing on or before November 15th of the current tax year. Any change in W-2 Services after November 15th may result in Employees receiving Forms W-2 after January

    31st or possible duplicate forms issued from both Renaissance and Policyholder/Employer.

    CHANGING FICA MATCH TAX SERVICE SELECTION

    Policyholder/Employer agrees that any service change regarding Employer FICA Match service will be effective on January 1st following the date on which a new Tax Service Authorization has been signed and submitted to Renaissance.

    ACCURATE AND TIMELY INFORMATION

    Policyholder/Employer agrees to provide Renaissance with accurate and timely information to provide selected tax services, including information to determine the taxable portion of the benefits. Submission of incorrect taxable portion of benefits by the Policyholder/

    Employer which later requires Renaissance to retroactively correct claimant net benefits may result in fees payable to Renaissance to cover reasonable processing.

    HOLD HARMLESS

    Policyholder/Employer agrees to indemnify and hold Renaissance harmless from any and all liability, including but not limited to fines or penalties that may result from erroneous (including omitted), incomplete, or untimely information provided by Policyholder/Employer to Renaissance in connection with the selected tax services and Renaissance’s performance of its duties under this Authorization.

    PRICING FOR SELECTED TAX SERVICES

    Policyholder agrees that the FICA Match Service will require underwriter review. If selection of this service results in a change in premium, Renaissance will promptly notify Policyholder. Election for FICA Match Service remains in effect until notification of termination of service.

    TERMINATION OF SERVICES

    If the policy or policies under this Authorization are terminated for any reason, the Policyholder will be responsible for reporting the FICA tax for new claims. Renaissance will only be responsible for providing FICA Match Service for the period that the policy is in force. If the Policy is terminated, Renaissance will continue to provide and file Form W-2 for disability benefits/sick pay payments on all claims incurred prior to termination of the Policy.  Employer agrees that this Authorization may be terminated by either party giving 60 days written notice.

     

  • Electronic Signature Agreement

  • DO NOT CANCEL OTHER COVERAGE UNTIL NOTIFIED IN WRITING BY RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF AMERICA ("THE COMPANY") OF ACCEPTANCE OF THIS APPLICATION.

    The undersigned, who is an officer of {employerName} and authorized to enter into this contract, certifies the following to be true:

    1. all answers containerd herein are true and complete;
    2. the Company may institute inspection reports with regards to questions answered herein;
    3. the Company may decline acceptance of the Application or, where permitted by law, and any person for whom coverage is requested
    4. no coverage will become effective under the plan of insurance until written approval is received from the Company; and
    5. that the Company may terminate the policy(ies) by giving advance written notice as required by the Policy.

    By typing your name in the signature panel below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By signing your name in the signature panel above, you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Affinity Group Underwriters / {insurer} instructions via e‐mail or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E‐Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E‐Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E‐Signature or any resulting contract between you and {insurer}. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement.

     
  • Signature Date*
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