Common Contracts

Plan Service Agreement and Employer Information

March 14th, 2016

• Filed
  March 14th, 2016

EMPLOYER DATA 1. Full Legal Business Name: 2. Full Legal Address: 3. Group Phone Number: 4. Federal Tax ID No.: Choose One:  Sole Prop  C-Corp  S-Corp  Partnership5. Association Affiliation: 6. Fiscal Year Ending: 7. Administrative Contact Person: 7a. E-mail address: 8. Executive Contact Person: 8a. E-mail address: 9. HIPAA Privacy Information Contact Person: 9a. E-mail address: 10. Names/Addresses of subsidiaries/affiliates to be included: 11.  Yes  No If subsidiaries are included, do you want separate bills sent to each of these subsidiaries/affiliates?12. Legal name of the Plan: Health Plan13.  Yes  No Is the Plan maintained through a trust? If yes, list name and business address of all trustees. 14.  Yes  No Is the group currently with a PEO? If yes, name of PEO: 15.  Yes  No Is this group a government agency or church group?16.  Yes  No Is the Plan subject to collective bargaining?If yes, union name: Exp. Date: 17. Name of person for service of legal process: 17a.