Group Policy Installation Form

Transcription

1 Group Policy Installation Form Fill all sections of this form applicable to the installation of your group policy. Please provide this form along with the Employer Application for Group Insurance. 1. Coverages Requested Do you have existing group insurance with Principal? *If Yes, as an Existing Client, what did you make changes to? Check all that Dpply: Request for New Coverage Amending Current Benefits Employer Information Employee Eligibility List other changes: Check all coverages you are enrolling in with Principal Life: Dental Voluntary Dental Vision Voluntary Vision Basic Life AD&D Voluntary Life AD&D Short Term Disability Voluntary Short Term Disability Long Term Disability Voluntary Long Term Disability Voluntary Critical Illness 2. Contact Information Company Legal Group Contact: Do you have contact information that is different from the Group Contact Information you provided above? e.g. Billing Contact Information or Primary Online Access Contact *If yes, complete additional contact information relevant to your company: Billing Contact Information: 1

2 Primary Online Access Contact Information only needed if different than above: 3. Billing Mailing Information Billing Type? List Bill: Principal Life will generate a monthly bill for your company SelfAccounting: restrictions apply and additonal agreement forms are required Is the Billing Address different from the Physical Address provided on the Employer Application? *If Yes, provide your preferred Billing Location: Street PO Box: City: State: Zip Code: Separate Bills Requested? : Fill in Box Below *If, would you like Divisional Billing for your single bill? Yes Employee Enrollment formscensus must illustrate divisions for each employee Employee enrollment formscensus must illustrate billing unit name for each employee *If Yes, where would you like the Separate Bills to be sent? Billing Location Billing Location and Additional Locations See Section 10 to list additional billing addresses Would you like Voluntary Coverages to be broken down to match your payroll? This breakdown will be included in your monthly bill. *If Yes, select payroll mode and provide requested information: Weekly Please provide the last payroll date prior to effective date MM BiWeekly Please provide the last payroll date prior to effective date MM Semily Please provide the last 2 payroll dates prior to effective date MM MM 2

3 4. Enrollment: During your first enrollment, will you be providing an EXCEL Census? Yes: agreement required Are you utilizing an Electronic Data Interchange efile Vendor? Yes: agreement required DentalVision: Should the annual enrollment period be one month prior to the policy anniversary date? : provide alternative enrollment period below Alternative enrollment period date: MM Yes Standard option 5. Job Classes and Waiting Periods: What is the waiting period for all members? If waiting periods vary by job class, refer to Section 11. Current Members: Hired prior to effective date: ne Future Hires: ne Indicate # of days Indicate # of days Indicate # of months Indicate # of months Affordable Care Act ACA Orientation Period: The ACA rules permit an employment based orientation period before the application of ZDLWLQJ period limits. Orientation Periods do not apply to Principal Products and are calculated separately. Does your waiting period with Principal Life need to begin after the company Orientation Period? *If Yes, complete this section: What is the duration of the Orientation Period? up to a maximum of 30 days or 1 month Number of s: te: Waiting period starts after the orientation periods ends. The member's hire date will be listed as the day after the orientation period is satisfied. 6. Eligibility: When are employees eligible after the waiting period? immediately following the final day of waiting period First day of insurance month coinciding with or following final day of the waiting period Check to remove coinciding wording from above option. By removing Coinciding employees effective on the 1st of the month will wait an additional month to be eligible for coverage 3

4 When should coverage be terminated? Last day employee worked or was part of eligible job class Last day of the insurance month employee worked or was part of eligible job class Do you have any classes of employees or locations that are not eligible for coverage? Yes List ineligible job classes or locations Example: parttime, nonmanagers, union, etc Will domestic partners be covered? State restrictions may apply *If yes, indicate definition of Domestic Partner: Same sex only Same and opposite sex Number of total employees on payroll: Number of eligible employees based on eligibility hours: 7. Employer Contributions: Employer Coverage Contributions: Dental: Retiree*: Vision: Retiree*: Basic Life: Retiree*: Voluntary Life: Critical Illness: Short Term Disability: Long Term Disability: *If requesting Retiree Coverage, indicate type of retirees to be covered Restrictions Apply: Please choose one option: Current Retirees Future Retirees Both Current and Future Optional: List definition of retiree if your company wants additional rules around retiree coverage. At least years of service and at least years old. 4

5 8. Product Information: Did your company have coverage with a prior carrier? *If Yes, complete prior carrier information: Effective Date: MM YYYY Termination Date: MM YYYY Coverage Included: Effective Date: Termination Date: MM YYYY MM YYYY Coverage Included: Dental: If prior carrier covered dental, please fill in box below: Dental Prior Carrier Information: Did the prior carrier dental benefits include orthodontia treatment? Yes Did prior dental coverage include maximum accumulation max rollover, max builder? Yes provide prior carrier report showing individual maximums accumulated Dental and Vision: ID Cards Shipping Location? Employer Main Location Employer BIlling Address Employee Home address please note that this option may take longer to receive DentalVision: Does the group qualify for COBRA? COBRA eligibility is defined as employers who employed 20 or more full and fulltime equivalent or parttime employees on at least 50 of the working days in the prior calendar year.. Be sure to obtain COBRA enrollment for anyone currently on COBRA. *If yes, please indicate billing for COBRA: Group bill policyholder Direct bill COBRA continuee What is the definition of compensation for benefits based on salary? Basic Life, VTL, STD, LTD Base wage excludes bonus, commissions, overtime Base wage with bonus* Base wage with commission* Base wage with bonus and commission* W2* *For bonuscommissionw2, select the year average: 1 year average 2 year average 3 year average 5

6 9. ERISA Information: Does ERISA apply? ERISA ERISA Plan Number: ERISA Plan Number: Coverages: Coverages: Ending date of plan s fiscal year: Fiduciary and ERISA Plan Administrator: MM YYYY The Employee Retirement Income Security Act of 1974 ERISA requires that each employee benefit plan subject to the Act designate a Named Fiduciary who shall have authority to control and manage the operation and administration of the plan. Are the Named Fiduciary and ERISA Plan Administrator an entity OTHER THAN the company legal name? legal name of company is recommended Named FiduciaryPlan Administrator: te: Most companies list their ERISA Plan AdministratorNamed Fiduciary as the Company Legal Name. By listing a specific person or entity other than the policy holder, you will be responsible for contacting us, filing paperwork, and reconfirming ERISA information every time the FiduciaryPlan Administrator changes. If you are sure you want to name a Fiduciary and Plan Administrator, please fill in the information below: Named Fiduciary Plan Administrator Address: Street PO Box: City: State: Zip Code: Thank you for completing the Group Policy Installation Form. Please make sure all the information you provided is correct or the best to your knowledge and confirm that additional applications are attached to the back of this packet. If you have any questions about this form please call. 6

7 10. Additional Locations: *Additional Location Information Location Street PO Box: City: State: Zip Code: Contact Number of Employees: Division Billing? Yes Employee Enrollment formscensus must illustrate divisions for each employee Return to Form Location Street PO Box: City: State: Zip Code: Contact Number of Employees: Division Billing? Yes Employee Enrollment formscensus must illustrate divisions for each employee Return to Form 7

8 11. Additional Job Classes: Job Class Information Job Class Coverages: Job Class Specific Waiting Period:Disregard Waiting Period section if previously stated waiting period is same for all job classes Current Members: Hired prior to effective date: ne Future Hires: ne Job Class Information Job Class Coverages: Job Class Specific Waiting Period:Disregard Waiting Period section if previously stated waiting period is same for all job classes Current Members: Hired prior to effective date: ne Future Hires: ne 8