GROUP HEALTH INSURANCE

Employer Information
First Name:
Last Name:
Company Name:
Street Address:
City:
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Zip Code:
E-mail address:
Who Referred You:
Employer is a: Corporation Partnership Sole Proprietorship Other   Explain:
Company Contact Person:
Contact Phone Number:	-   -
Contact Fax Number:	-   -
Date business was established:
Type of Business:
Employee Eligibility
Total Number of Employees:
Number of eligible full-time employees(min 30hrs. week):
Are part-time employees(20-29hrs. week) to be covered?   Yes   No
Are all eligible employees subject to federal withholdings on a w-2?   Yes   No
Total number of eligible ENROLLING employees:	<>
Number of eligible employees DECLINING coverage:	<>
Number of INELIGIBLE employees: Reason for ineligibility:
Do you wish to offer coverage for "Domestic Partners"?   Yes   No
Coverage Information
Probationary(waiting) period for new employees:
Requested Effective Date:
Is your group subject to COBRA? (20 or more employees working 50% of the calender year):   Yes   No
Is your group subject to Cal-COBRA coverage? (2-19 full-time employees working 50% of the calender year):   Yes   No
Is your group subject to the Family Medical Leave Act of 1993? (50, or more, total employees):   Yes   No
Current Carrier
Is this plan intended to replace existing group Health coverage?   Yes   No	Name of Group Health Carrier:
Is this plan intended to replace existing group Dental coverage?   Yes   No	Name of Group Medical Carrier:
Health Termination Date:	Dental Termination Date:
Current worker's compensation carrier:  Policy Renewal Date:

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