Annual Pre-Renewal Verification

BUSINESS INFORMATION

Legal Company Name *

DBA (if applicable)

Date Established *

Physical Address *

Mailing Address

Additional Locations *

Company Phone *

Fax Number

SIC/NAICS Code *

Tax ID Number *

UBI Number *

Business Structure *

C-Corp
S-Corp
LLC
Partnership
Sole Prop
Public Entity
Non-Profit
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OWNER/CEO INFORMATION

CEO Name *

CEO Phone *

CEO Email Address *

HR BENEFIT ADMINISTRATORS

Administrator Name *

Administrator 2 Name

Administrator Title *

Administrator 2 Title

Administrator Phone *

Administrator 2 Phone

Administrator Email *

Administrator 2 Email

Section 125 POP Plan Current? *

Yes
No
Don't know
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Attach Section 125 POP Plan (New Groups Only)

EMPLOYER CONTRIBUTIONS

Medical: Employee *

Medical: Dependent *

Dental: Employee *

Dental: Dependent *

Vision: Employee *

Vision: Dependent *

Notes on Multiple Medical Offerings *

Please note any special considerations on contributions for multiple plans, such as "we only charge the employee $50 for the buy-up option"

TOTAL EMPLOYEE COUNT

Total on Payroll *

Full Time *

Part Time *

Union *

Temporary *

CLASSIFICATIONS / CLASS

Probation Period *

PT to FT Policy *

Waive Probation Period
Do Not Waive Probation Period
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Min. Hours Per Week *

Variable Hour Tracking?

Yes
Not Applicable
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Pay Dates *

Payroll Frequency & Do you deduct from every check? *

Re-hire Provision *

30 Days
60 Days
90 Days
None
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Payroll Provider *

Fiscal Year *

ERISA Plan Year *

Lookback Period for Variable Hour EEs *

Not Applicable
3 months
6 months
9 months
12 months
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Are spouses eligible for coverage? *

SIGNATURES

Completed By (Signature) *

Date Completed *

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Notes

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