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ePOP Data Requirements for Web entry
Company Information
*
Indicates required field
Territory Manager Last Name
*
DGA Last Name
*
Company Name
*
Company Phone Number
*
Company Email Address (Plan Administrator)
*
Company Address
*
Line 1
Line 2
City
State
Zip Code
Country
Plan Administrator Name
*
Number of Employees
*
Agent email address to send ePOP documents
*
State of Legal Construction
*
Federal Tax ID Number
*
Legal Entity Type
*
Legal Entity Type: C-Corp, S-Corp, Sole Proprietorship, Partnership, Non-Profit, LLC or Government Entity
Is this a church or Government entity?
*
Neither
Church
Government
Is this an amendment to the original plan?
*
Yes
No
If "Yes" what was the original Effective date of the plan?
*
What is the effective date of the amendment?
*
Current Plan Year Start Date
*
Current Plan Year End Date
*
Eligibility Requirements
Waiting Period
*
Hours per Week
*
Months Per Year
*
Date of Eligibility
*
1st of the Month Following Waiting Period
Immediately Following the Waiting Period
15th of Month Following Waiting Period
Are union employees eligible?
*
No
Yes
Not Applicable
Are seasonal employees eligible?
*
No
Yes
Not Applicable
If "yes", what is the maximum number of consecutive work weeks an employee must work to be classified as seasonal?
*
Benefits
Benefits being offered on
pre-tax
basis
Please select all that apply.
*
Health
HSA
Vision
Dental
Cancer
Accident
Hospital Confinement/Bridge/GAP
Other (Leave notes)
If other, please detail notes here.
*
Optional HSA Amendment Language
Health Savings Account contribution?
*
No
Yes
HSA Amendment Effective Date
*
Optional Enrollment type language
Check all that apply.
*
Negative/Default Enrollment (automatic enrollment when eligible)
Evergreen/Rolling Enrollment (elections roll over from year to year)
Affiliates
(List associated companies covered by this POP plan)
Affiliated Employer Name #1
*
Affiliated Employer Name #2
*
Affiliated Employer Name #3
*
Signatory
Agent Name
*
First
Last
Agent Code
*
Date (MM/DD/YY)
*
Submit
Home
Agent Services
Ameriflex ePOP
New & Existing Case Checklist
Client Resources
Enrollment
HR Answers Now
About
Experiences
Contact
