Fillable ERISA Administration Change Form

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ERISA Administration Change Form

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The ERISA Administration Change Form form is 1 page long and contains:

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  • 1 check-box
  • 73 other fields

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File type: PDF

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ER-4235-032921
ERISA Administration Change Form
Client Name: ________________________________ Client ID: ________________________________
• Anticipated number of enrolled employees as of the first day of your new Plan Year
(including those on COBRA): ☐ 1-99 ☐ 100 or more
• Are you considered an Applicable Large Employer (ALE) under the Employer Shared Responsibility
provision of the Affordable Care Act (ACA) and are you currently tracking employee hours to
determine if any variable hour, part-time, or seasonal employees are “full-time” employees for
purposes of health plan eligibility? ☐ Yes ☐ No
• Upon renewal, the status of your Group Health Plan offered to employees will be:
☐ Grandfathered ☐ Non-Grandfathered
• Detail changes to benefits below.
No changes to benefit plans: ☐
Change Codes:
(1) Change of Carrier
(2) Change of Contract Period
(3) Change of Insured Status
(4) Add New Benefit
Health
Effective Date
of Change
Dental ____________
Vision ____________
Life (employer paid)
Change
Details
Code
(include full carrier name, if different)
_____ ________________________________________
_____ ________________________________________
_____ ________________________________________
_____ ________________________________________
____________
AD&D (employer paid) _____ ________________________________________ ____________
Voluntary Life _____ ________________________________________ ____________
Voluntary AD&D _____ ________________________________________ ____________
Dependent Life _____ ________________________________________ ____________
Dependent AD&D _____ ________________________________________ ____________
STD _____ ________________________________________ ____________
LTD _____ ________________________________________ ____________
Wellness _____ ________________________________________ ____________
EAP _____ ________________________________________ ____________
Stop Loss * _____ ________________________________________ ____________
________________________________________ ____________
Voluntary Products
Other *
_____ ________________________________________ ____________
Confirm with your benefits advisor that these are Employer Sponsored Plans subject to ERISA.
Signature ____________________________________________
Date __________________________
The information in this communication is confidential and may be used by the authorized
recipient only for its intended purpose only. Any other use or disclosure is prohibited.
_____
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
Insured Status
(Fully-Insured
or Self-Insured)
____________
(5) Cancel Existing Benefit
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ERISA Administration Change Form

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Completed 18 May 2022

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