Employee Navigator New Group Implementation
Company Information
Group Legal Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Benefits Contact
*
First Name
Last Name
Benefits Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Benefits Contact Email
*
example@example.com
Number of Employees
*
State of Legal Construction
*
Federal Tax ID Number
*
SIC Code
*
Is this a Church, Government or other Legal Entity Type?
*
Church
Government
Legal Entity Type
Is this an amendment to the original plan?
*
Yes
No
What is the Original Effective date of the plan?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is the effective date of the amendment?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Plan Year Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Plan Year End Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Payroll Vendor
If available does the group want to integrate payroll?
Yes
No
COBRA Vendor
If available does the group want to integrate COBRA?
Yes
No
Self-Billing
If applicable, does the group want to utilize self-billing?
Yes
No
Eligibility Requirements
Eligibility Classes (if they have more than 1)
Ex: Full-Time, Part-Time, Management, etc.
Waiting Period
*
Days
Date of Eligibility
*
Please Select
Hire Date
1st of the month after
1st of the month coinciding with or after
15th of the month after
15th of the month coinciding with or after
Entry date
Hours per Week (If Full-Time is other than 30 hours)
Months per Year
Are union employees eligible?
Yes
No
Are seasonal employees eligible?
Yes
No
What is the maximum number of consecutive work weeks an employee must work to be classified as seasonal?
Core Benefits
Core Benefits being offered on a pre-tax basis (check all that apply)
*
Health
HSA
Vision
Dental
Group Term Life
Disability
Critical Illness/Cancer
Accident
Bridge/Gap
Hospital Confinement
Other
Optional HSA Amendment Language
Are there employer HSA contribtuions?
Yes
No
Health Savings employer contribution
HSA Amendment effective date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Optional Enrollment Type Language
Check all that apply
*
Negative/Default Enrollment (Employees are automatically enrolled in the pre-tax plan when first eligible.)
Evergreen/Rolling Enrollment (Employee elections roll over from year-to-year.)
Affiliates
Please list all other associated companies covered by this POP plan
Affiliated Employer Name #1
Affiliated Employer Name #2
Affiliated Employer Name #3
Pay Information
Pay Schedule
*
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Next Pay Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Benefit Deductions
*
12
24
26
52
Other
Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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