Company Name

First Name

Last Name

Email Address

Phone Number

Job Title

Form Submitted By: Employee RepresentativeAdvisor / Broker / ConsultantCurrent UnifyHR Customer

Return Proposal To: Employer RepresentativeAdvisor / Broker / ConsultantBoth Parties

Desired Effective Date

I'm interested in: ACA Comprehensive Services Yes No Please select Yes or No

I'm interested in: ACA Reporting-Only Services Yes No Please select Yes or No

ACA Desired Reporting Year Please enter the desired year in the format YYYY. NOTE: Our ACA services are based on the tax year (e.g., the information filed in January 20X1 is for the 20X0 tax year). Any requests for services starting after October 31 must be for the following tax year, e.g., services starting in January 2025 cover the 2025 tax year with filing in January 2026.

ACA Organization Info | # of Measured Lives All full-time, part-time, seasonal and variable-hour employees subject to measurement.

ACA Organization Info | # of Reportable Lives Number of 1095-C forms mailed last tax year.

I'm interested in: Billing Services Yes No Please select Yes or No

Billing | # of Current Billing Participants e.g. Retirees, LOA, etc.

I'm interested in: COBRA Administration Yes No Please select Yes or No

COBRA | # of Benefit-Eligible Employees

COBRA | # of Covered Employees

COBRA | # of Current COBRA Participants

I'm interested in: Eligibility Verification Services Yes No Please select Yes or No

EVS | Employee Total

EVS | Benefit-Enrolled Active Employees

EVS | Total # of Employees Covering Independents in Health Plan(s) Number of employees with one or more enrolled dependents.

EVS | Average Annual Employer Cost per Dependent

EVS Optional Services | Do you wish to audit spousal surcharge participants? YesNo

EVS Optional Services | # of Employees Covering Spouses

EVS Optional Services | Do you currently maintain SSN’s for all dependents? YesNo

EVS Optional Services | Do you wish to collect dependent SSN’s? YesNo

I'm interested in: Print & Mail Fulfillment Yes No Please select Yes or No

Print & Mail Fulfillment | Notice Type New Hire NoticesEmployee Onboarding PacketsMarketplace NoticeCOBRA General NoticesHIPAA Privacy NoticeLife Status Change NoticesWomen’s Health and Cancer Rights Act NoticesPremium Only Plan (POP) CommunicationsSummary of Benefits and Coverage (SBC) NoticesERISA NoticesFMLA NoticesRetirement Communication PacketsMedicare Part D NoticeOpen Enrollment Communication PacketsCustom Regional NoticesSpecial Request

I'm interested in: State Filing Services Yes No Please select Yes or No

State Filing Services | Select State(s) CaliforniaDistrict of ColumbiaMassachusettsNew JerseyRhode Island

Organization Structure | Current Benefit Administration System Please list all if more than one.

Additional Information Please provide any additional important details about your request.

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