Original Plan Name:
OPName
Original Plan Effective Date:
OPEffDate
Employer / Plan Sponsor's Full Legal
Name:
PSName
Employer / Plan Sponsor's Federal Tax
ID Number:
PSFEIN
Employer / Plan Sponsor's Entity Type:
PSEntity
Employer / Plan Sponsor's Industry:
PSIndustry
Employer / Plan Sponsor's Number of
Full Time Employees:
PSCount
Employer / Plan Sponsor's Street
Address:
PSAddress
Employer / Plan Sponsor's Street
Address 2:
PSAddress2
Employer / Plan Sponsor's City:
PSCity
Employer / Plan Sponsor's State:
PSState
Employer / Plan Sponsor's Zip Code:
PSZip
Name of Authorizing Executive for
Employer / Plan Sponsor:
AEName
Title of Authorizing Executive for
Employer / Plan Sponsor:
AETitle
Phone Number of Authorizing Executive:
AEPhone
E-Mail Address of Authorizing
Executive:
AEEmail
Name of Plan Administrator / Human
Resources Contact:
PAName
Phone Number of Plan Administrator /
Human Resources Contact:
PAPhone
Month of Most Recent Health Insurance Plan Renewal:
RenewalMO
Year of Most Recent Health Insurance
Plan Renewal:
RenewalYR
The Current Health Insurance Plan Year
is 12 Months:
CurrentPY
If False, the Current Health Insurance
Plan is How Many Months:
PYNext
How Frequent Are Payroll Deductions To
Fund Premiums:
PayFreq
When Do Payroll Deductions Occur For
Monthly Coverage Period:
DedSched
Health Insurance Agent's First Name:
IAFirstName
Health Insurance Agent's Last Name:
IALastName
Health Insurance Agent's Phone Number:
IAPhone
Comments:
Comments
