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Industry Agriculture Apparel Banking Biotechnology Chemistry Communications Construction Consulting Education Electronics Energy Engineering Entertainment Environmental Finance Food & Beverage Government Healthcare Hospitality Insurance Manufacturing Media Not-For-Profit Recreation Retail Shipping Technology Telecommunications Transportation Utilities Other

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

Return Proposal To: Employer RepresentativeAdvisor / Broker / ConsultantBoth Parties

Proposed 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

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

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

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

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

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

Organization Structure | Total # of Data Interfaces Each distinct platform or system that maintains required ACA data such as Payroll, HRIS, Benefit Enrollment, Time & Attendance, COBRA, or other similar system.

Organization Structure | Health Insurance Plan Type Fully-insuredSelf-insured

Organization Structure | HR Function Performed At Corporate LevelDivision LevelOther

Organization Structure | # of Divisions / Subdivisions

Organization Structure | # of FEINs

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

Organization Structure | Current Payroll System(s) Please list all if more than one.

Organization Structure | Billing / Invoicing Requirements Single Corporate InvoiceDivisional Level InvoiceOther

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 anticipated 1095-C forms for this tax year OR the number of 1095-C forms produced last tax year.

ACA Organization Info | Measurement Method MonthlyLookbackUnknown / TBD

ACA Organization Info | Length of Measurement Period 3 Month Stability Period4 Month Stability Period6 Month Stability Period12 Month Stability PeriodOther

ACA Organization Info | Affordability Safe Harbor Federal PovertyRate of PayW2Unknown / TBD

ACA Organization Info | # of ACA-Eligible Medical Plans

Billing | # of Benefit-Eligible Employees

Billing | # of Covered Employees

Billing | # of Current Billing Participants

Billing | # of Health Plans

COBRA | # of Benefit-Eligible Employees

COBRA | # of Covered Employees

COBRA | # of Current COBRA Participants

COBRA | Average # of Monthly New Hires

COBRA | Average # of Monthly Terminations

COBRA | # of COBRA-Eligible Health Plans

COBRA | # of Divisions

EVS | Employee Total

EVS | Enrolled Employees All Covered Individuals (including FTE’s, COBRA Continuants, Retirees, etc.)

EVS | Eligible Lives

EVS | Organizational Turnover Percentage (%) Please enter the percentage as ##%.

EVS | Total # of Employees Covering Independents in Health Plan(s) May include COBRA Continuants, Retirees, or other if applicable.

EVS | Total # of Dependents Covered by Health Plan(s)

EVS | Average Employer Cost per Dependent

EVS | Plan Year Start Date

EVS | Open Enrollment Begin Date

EVS | Open Enrollment End Date

EVS Optional Services | Does your health plan include a spousal surcharge? YesNo

EVS Optional Services | Do you wish to audit the 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

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

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

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

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