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Enrollment Application

Date of Submission: MM/DD/YYYY

Date of Quote Needed: MM/DD/YYYY

Plan Effective Date: MM/DD/YYYY

Broker Information

Broker Name: Address: City:

State:

Phone #: XXX-XXX-XXXX

Fax #: XXX-XXX-XXXX

Email:

New Group Information

Name: Address: City:

State:

Zip Code:

Phone #: XXX-XXX-XXXX

Fax #: XXX-XXX-XXXX

Employer Identification Number: Email Contact Person Plan Number (501?) Group SIC Code

Requested Effective Date: MM/DD/YYYY

Waiting Period For New Employees Total Number of Employees Total Enrolling in this Plan

Does this contractor have a Group Health Plan? Yes No

Does this contractor have a Group Pension Plan? Yes No

Does this contractor use prevailing wage fringe contributions to fund a Group Health or Pension Plan? Yes No

If "YES", how much is contributed to each plan?

Does this contractor perform the following: Service Contract Act %
DavisBaconAct %
Other %

Proposal Information

Please check the items you wish include_d in your proposal Flex Account MasterCard® Debit Card
Mail Order Pharmacy Transportation/Parking
Dependent Day Care Option* Tuition Assistance Program
*Dependent Day Care amounts are determined by the employee and must be reported to the IRS on a W-2 Form

Census Information

Complete the following ONLY if detailed census is not attached.

Average Age of Employees: Percentage Male vs. Female: Number Single: Number EE+1: Number Family: Other

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