Ameriflex ePOP

ePOP Data Requirements for Web entry

Waiting Period *

Hours per Week *

Months Per Year *

Date of Eligibility *

Are union employees eligible? *

Are seasonal employees eligible? *

If "yes", what is the maximum number of consecutive work weeks an employee must work to be classified as seasonal? *

Core benefits being offered on pre-tax basis

If other, please detail notes here. *

Health Savings Account contribution? *

HSA Amendment Effective Date *

Check all that apply. *

Negative/Default Enrollment (automatic enrollment when eligible) Evergreen/Rolling Enrollment (elections roll over from year to year)

Affiliated Employer Name #1 *

Affiliated Employer Name #2 *

Affiliated Employer Name #3 *

Agent Name *

First

Last

Agent Code *

Date (MM/DD/YY) *

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