Group Setup / Configuration

Company Information

Group Name *

FEIN / EIN *

SIC Code

Standard Industry Classification code

Industry Description

Primary Contact Name *

Primary Contact Title

Primary Contact Email *

Primary Contact Phone *

HQ Address

Street Address

Suite / Floor

City

State

ZIP Code

Billing address same as HQ

Billing Address

Street Address

City

State

ZIP Code

Plan Selections

Select plans to offer this group. Configure enrollment tiers per plan.

HMO Gold Most Popular

Monthly Premium

Coverage Tier	Total Premium	Employer $	Employee $
Employee Only
Employee + Spouse
Employee + Child(ren)
Family

HMO Silver

Coverage Tier	Total Premium	Employer $	Employee $
Employee Only
Employee + Spouse
Employee + Child(ren)
Family

PPO Silver

HMO Bronze

Contribution Rules

Employer Contribution Method

Percentage of premium Flat dollar amount

Contribution per Tier

Tier

Employer Contribution

Max Employee Cost

Employee Only Employee + Spouse Employee + Child(ren) Family

Eligibility Rules

Waiting Period

Employment Type

Minimum Hours / Week

Applies to part-time eligibility

Dependent Age Limit

Allow late enrollment with evidence of insurability

Allow mid-year enrollment for Qualifying Life Events (QLE)

Plan Year

Plan Year Start *

Plan Year End *

Open Enrollment Start

Open Enrollment End

Late Enrollment Deadline

Late Enrollment Rules