Admin America POP Plan Revision Order Form

Admin America

POP Plan Revision Order Form

Please complete the below form.

All fields with a * must be completed.

Please contact XXXX if you have questions or are experiencing difficulties with this form.

* Original Plan Name:

* Original Plan Effective Date:
Please Note: Only Plans After 01/01/1995
Enter as xx/xx/xxxx

* Employer / Plan Sponsor's Full Legal Name:

* Employer / Plan Sponsor's Federal Tax ID Number:
Enter as xx-xxxxxxx

* Employer / Plan Sponsor's Entity Type:

* Employer / Plan Sponsor's Industry:

* Employer / Plan Sponsor's Number of Full Time Employees:

* Employer / Plan Sponsor's Street Address:

Employer / Plan Sponsor's Street Address 2:

* Employer / Plan Sponsor's City:

* Employer/Plan Sponsor's State:

* Employer / Plan Sponsor's Zip Code:
Enter as xxxxx or xxxxx-xxxx

* Name of Authorizing Executive for Employer / Plan Sponsor:

* Title of of Authorizing Executive for Employer / Plan Sponsor:

* Phone Number of Authorizing Executive:
Enter as xxx-xxx-xxxx

* E-Mail Address of Authorizing Executive:

* Name of Plan Administrator / Human Resources Contact:

* Phone Number of Plan Administrator / Human Resources Contact:
Enter as xxx-xxx-xxxx

* Month of Most Recent Health Insurance Plan Renewal:

* Year of Most Recent Health Insurance Plan Renewal:

* The Current Health Insurance Plan Year Is 12 Months:

True False

* If False, the Current Health Insurance Plan Is How Many Months:
Enter as xx (Enter 00 if True)

Months

* How Frequent Are Payroll Deductions To Fund Premiums?

* When Do Payroll Deductions Occur For Monthly Coverage Period?

Health Insurance Agent's First Name:

Health Insurance Agent's Last Name:

Health Insurance Agent's Phone Number:

Comments:

Admin America, Alpharetta, GA
Phone: (770) 992-5959 or (800) 366-2961 e-mail: info@adminamerica.com