Aflac Group Re-enrollment Confirmation

Transcription

1 Aflac Group Re-enrollment Confirmation INSTRUCTIONS This form should be used for all Aflac Group re-enrollments. Using this form will expedite the re-enrollment process. All fields are required unless otherwise noted. Submit completed forms to your state office for approval and submission to Aflac Group. Today s Date: Group Account Number: Name of Account: OSA/Field Contact Name: Writing #: Market Op: Offering same products as last year? Yes (Complete Sections 1 and 2 and Signature Page (sections 4 and 5) ONLY. If Group SNG, also complete Section 6.) Adding additional group products/change to existing SHI Admission Benefit (HI 8500/8800 only)? Yes (Complete entire form) 1. Type of Business: Tax ID No.: Situs State (situs/headquarters/domicile state): Number of Eligible Employees: Mailing Address: City: State: ZIP: Number of Locations: if multi-location account, list states: * Does this account employ residents of Massachusetts? Yes No 2. ENROLLMENT INFORMATION Enrollment Method(s): 1 on 1 paper 1 on 1 Group SNG (complete Section 6) 1 on 1 Third-Party Laptop Call Center Web HR/Group Meetings Enrollment Data: Paper Electronic File NOTE: Third-Party Laptop, Call Center, and Web enrollment methods may result in commission reduction. Refer to the electronic enrollment guidelines on Associate Services for additional requirements. All vendors must be approved prior to submission of R0138. *Enrollment Dates: Start: End: Coverage/Billing Effective Date: *Enrollment forms cannot be solicited more than 90 days prior to the coverage/billing effective date. Enrollment forms taken outside the dates specified above will be automatically declined unless they are new hires able to enroll during the year. Deductions must begin in the month of the coverage/billing effective date. Submission Date (Date enrollment forms will be received by Aflac Group): / / Current submission guidelines apply: Paper Enrollment within 5 calendar days after enrollment end Electronic Enrollment within 10 calendar days after enrollment end Date group products last offered to employees at this account / / (This determines who is a newly eligible employee vs. a late enrollee.) Date Deduction file due to account after initial/re-enrollment: / / Full deduction file New enrollees only deduction file (Applies to accounts over 500 lives only) Will newly eligible employees be enrolled throughout the year? Yes No If yes, with what frequency will they be enrolled? Monthly Quarterly Semiannually Other R Rev February

2 Payroll Frequency Information: Check if premiums are employer paid. Check if premiums are deducted at different frequencies for different employees (i.e., some employees are deducted weekly while others are deducted biweekly). If this is the case, please check all that apply below: Deduction Frequency List the dates of the first and second deduction for each deduction frequency: Weekly (52 paychecks) *First Deduction: / / Second Deduction: / / Biweekly (26 paychecks) *First Deduction: / / Second Deduction: / / Semimonthly (24 paychecks) *First Deduction: / / Second Deduction: / / Monthly (12 paychecks) *First Deduction: / / Second Deduction: / / Other: *First Deduction: / / Second Deduction: / / If Other, please provide dates that payroll deductions will not be made: Enrollment Contacts - must address OSA / Field Contact Address: City: State: ZIP Code: OSA Contact Title: Contact Address: Telephone: Fax: Second Field Contact Name (if applicable): Address: City: State: ZIP Code: Contact Title: Contact Address: Phone: Fax: Is the MLA department at WWHQ being utilized? Yes No If Yes, Contact name; Is there a broker involved? Yes No If Yes, is it the same broker as last enrollment? Yes No If no, complete below: Broker Firm/Consultant: Broker Name: Broker Address: City: State: ZIP Code: Contact Name: Contact Title: Contact Address: Contact Phone: Contact Fax: Servicing Broker Indicator: Check here if the broker should be listed as a consultant Employee ID # for broker relationship manager or non-commissioned representative (i.e. Consultant): R Rev February

3 Is there an enrollment firm/third party vendor involved? Yes No If Yes, complete below: Enrollment Firm Name / Third Party Vendor (if applicable): Enrollment Firm Address: City: State: ZIP Code: Enrollment Firm Contact Name: Contact Title: Contact Address: Contact Phone: Contact Fax: 3. GROUP PRODUCTS BEING ADDED Please check the box for each group product you will be offering during this enrollment: Critical Illness Advantage Tobacco-Distinct Rates Uni-Tobacco Rates Include Additional Benefits (loss of sight, speech, hearing, coma burns paralysis) Health Screening Benefit Without Cancer Optional Benefits Rider (BTAP) Heart Rider Occupational HIV Rider (healthcare cases only) Building Benefit Rider Progressive Diseases Rider (ALS and MS) Accident Select only one: Low Option Mid Option High Option Select only one: Aflac New York (situs state NY) Plan 1 Plan 2 Plan 3 Plan 4 Select only one: Non-occupational Select only one: With Wellness 24-Hour Without Wellness Sickness Rider Catastrophic Rider HSA Compatible (subject to availability)* *Only Catastrophic Rider is available on HSA Compatible plan for Accident Group Hospital Indemnity HSA Compatible Plan Needed Dental Hospitalization Category Building Benefit High Mid Yes No Low Health Screening Benefit (only available on HSA Compatible plan OR if Treatment Category is NONE) Yes Treatment Category No High Mid Low None Surgery and Anesthesia Category Inpatient and Outpatient Outpatient Only High Mid Low Select only one: Basic Plan Whole Life Standard Premier None Face Purchase Premium Purchase (only available for cases over 1,000 lives) Term Life (only two selections per payroll account) 5-Year 10-Year 15-Year 20-Year 30-Year R Rev February

4 Short-Term Disability Select only one: 24-Hour Benefit Nonoccupational Select only one: Benefit Period: 3-Month 6-Month 12-Month Select only one: Elimination Period: 0/7 7/7 0/14 14/14 30/30 (available on 6 or12 month benefit period only) 90/90 (available on 12 month benefit period only) Pre-existing Condition Benefit Mental Illness Limited Benefit Alcoholism/Drug Addiction Limited Benefit Continuity of Coverage PRE-TAX PLANS (Please complete if applicable) Which products and plans will be pre-tax? None Critical Illness Accident Hospital Indemnity Dental Short-Term Disability When does the plan year begin for the Aflac Group products? When does the traditional plan year begin? Will the account require Premium-Only Plan documentation from Aflac Group? Yes No 4. ASSOCIATE/AGENT AUTHORIZATION AND SIGNATURE(S) I acknowledge that I, as Broker or Securing Associate, am wholly responsible for servicing and maintaining my account(s) with Continental American Insurance Company (Aflac Group), and I will take all reasonable and expected efforts to do so properly. I further acknowledge that Continental American Insurance Company (Aflac Group) may assume the performance of any or all of my duties and responsibilities as Broker if Continental American Insurance Company (Aflac Group) provides notice that I have failed to properly service and maintain such account(s) and if I fail to cure said deficiencies within 10 days of such notice. I confirm that I am not an employee, officer, director, owner, or relative of any of the foregoing (or otherwise a party in interest as defined under ERISA. I understand that I am not authorized to collect premium from this account without specific written approval from Continental American Insurance Company (Aflac Group). I understand as the OSA for this account that I may be entitled to a split of commissions on all business written on this account (Master Application). Associate s/agent s Signature: Date: Associate s/agent s Name: Writing Number: Market Op: Phone Number: ( ) Fax Number: ( ) Commission Structure Code: Please indicate the Aflac Group commission structure code to be used for this enrollment in the field above. Please contact your Market Office or Account Implementation Coordinator (AIC) to submit the necessary assignment documentation for this enrollment. Missing commission or assignment information will cause a delay in account setup and processing. If requesting a new custom commission structure, please contact AVCustomCaseRequest@aflac.com. (new custom commission requests are only eligible for accounts over 2500 employees) R Rev February

5 5. MARKET OFFICE APPROVAL Please review, approve and submit to Title of Approver: Market Director Market Coordinator Market Trainer Signature of Approver: Printed Name of Approver: Market Operation: Date: SPECIAL INSTRUCTIONS/ADDITIONAL INFORMATION: Please include any additional special instructions/additional information as applicable: R Rev February

6 6. SNG-G SETUP INFORMATION NOTE: Complete only for cases requiring an SNGG enrollment. Name of Account: Field Underwriting allowed: Yes No Census Info Source: Core SNG Download with Case None *Employment Type: Full Time Part Time Main Contact for Enrollment setup, if different from OSA: Name: Address: Telephone: Enrollers: Agent Name Agent Writing Number State Enrolling SNG Unit # Location Code(s) Location Name(s) * For non-ci Wrap accounts, this information will be confirmed by the AIC during setup. Continental American Insurance Company Aflac Group Insurance PO Box 427 Columbia, South Carolina R Rev February