Employer Application Enrollment Group Contact First and Last Name*Group Contact Email* Group Contact Number*Are they also the Billing Contact?* Yes No Billing Contact Name*Billing Contact Email* Billing Contact Number*Company Name*Legal Name*Federal Tax ID Number*Company Nature of Business*Company Established Date* MM slash DD slash YYYY Company Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this also the billing address?* Yes No Billing Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Business*Business TypeS CorporationC CorporationSole ProprietorshipPartnershipLLCOtherIf other please describe*Are there any company subsidiaries or affiliates?* Yes No Please describe:*Number of hours worked to be eligible: (ACA considers 30 hours to be full time)* 20 25 30 Waiting Period in days: (effective at the first of the month following date of hire)* 0 30 60 Number of Full Time Equivalent Employees: For all employees included in the average total number of employees (below), calculate the average number of full-time equivalents for the preceding calendar year. The monthly full-time equivalents are calculated as follows: Number of full-time employees (who worked 30 hours or more per week on average); plus Total number of hours worked by part-time employees during the month capped at 120 hours, divided by 120. Number of Full time equivalent employees*Effective Date Requested:* MM slash DD slash YYYY Employer Contribution* Medical Dental Vision Supplemental Other Employer contribution (other)*Please tell us your expected contribution for your employee and their dependents. e.g. Employee: 65%; Dependents: 40%*Payroll Cycle* Weekly Monthly Semi-Monthly Bi-weekly Additional InformationCAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
