• Application must be completed in full, signed and dated for processing.
(1 of 5)
Employer Application
STEP 1 - COMPLETE EMPLOYER INFORMATION
City ZIP Code
Street Address (no P.O. Box) Suite/Unit #
State
Company Name
Residence
Yes No
DBA Name Exact Nature of Business
Contact Name
Contact Job Title
Contact E-mail Address
City ZIP Code
Mailing Address
Suite/Unit #
State
Residence
Yes No
County
County
(if different from above)
SECTION 125 - PREMIUM ONLY PLAN
(complete this section if you want this benefit) offered by CONEXIS Benefits Administrators (a division of WageWorks)
Note: A one-time $100 enrollment fee must be submitted with the premium deposit.
Name of Company President, Principal, or Partners
Last day of first plan year
(MM/DD/YYYY)
(Usually 12 months after the effective date of coverage;
subsequent plan years will be the 12 month period following this date.)
Participation Limitations: P.O.P. rules require that all participants in the plan be employees. Please be advised that 2% or greater shareholders in an S-Corporation, sole proprietors in
a Sole Proprietorship, and partners in a Partnership are not considered employees as defined by Tax Code, and therefore, are ineligible to participate. Important: Read the information
provided in your ChoiceBuilder® Quote pertaining to the Section 125 Premium Only Plan and tax consequences.
Date Business Started (MM/DD/YYYY) CA Federal Tax ID #
Contact Phone # (XXX) XXX-XXXX Contact Fax # (XXX) XXX-XXXX
• E-mail address underwriting@choicebuilder.com
Owner/President Name
Corporation
S Corporation
Sole Proprietorship
Partnership
LLC
Other
Company Structure
STEP 2 - COMPLETE ENROLLMENT & ELIGIBILITY INFORMATION
Yes No
Have you employed 20 or more employees during at least 50% of the preceding calendar year? (COBRA)
(In the State of California it is mandatory to offer benefits to registered
domestic partners in the same manner that is being offered to spouses.)
20+ hours per week 30+ hours per week
Select the number of hours an employee must work per week to be eligible for benefits
Total number of employees on payroll regardless of hours worked Total number of active eligible employees on payroll
(Including owners, partners, part-time, seasonal, etc.) (Including owners, partners, etc.)
Note: Upon request, the employer applicant agrees to provide documentation verifying the above numbers. (i.e. wage report, payroll records, etc.)
Number of employees
in the waiting period
Select who the waiting
period applies to
Date of Hire 30 days 60 days 90 days 180 days 365 daysWaiting period for future employees is first day of the month following
(Other options are not available, please do not write in)
future employees
current and future employees
(hired after effective date)
(hired on or prior to effective date)
Name of Corporate Secretary
(if applicable)
State of Incorporation
(if applicable)
Plan Number
(usually 501)
Medical Dental Vision Other
Premium payments may be elected for
SIC Code
CB 0210A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services
721 South Parker, Suite 200, Orange, CA 92868
Phone: (866) 412-9279 Fax (866) 412-9280
www.choicebuilder.com
REQUESTED EFFECTIVE DATE (MM/DD/YYYY)
Do you want to offer benefits
to non-registered domestic partners?
Yes
No
How many pay periods per year?
(will be shown on Employee Enrollment Worksheets)
12
24
26
48
52
Add Broker of Record as an Authorized Group Contact
43422
Ortho Min. Employees
(2 of 5)
STEP 3 - SETUP YOUR DENTAL PLAN
A. Select One Option
Employer Sponsored
Voluntary
(complete employer contribution section below)
(no employer contribution)
B. Select One PPO Carrier C. Do you want to
add orthodontic
coverage for the
PPO Carrier
Yes No
Option 1 - Percentage of Cost
Option 2 - Fixed Dollar Amount
Total number of ELIGIBLE employees APPLYING for coverage
Total number of COBRA beneficiaries APPLYING for coverage
Total number of ELIGIBLE employees WAIVING coverage due to
Other GROUP coverage
Other
INDIVIDUAL
coverage
OTHER reasons
Note:
eligible employees and dependents not
applying for coverage. Employees cannot
waive coverage if the employer’s
contribution is 100%, unless the waiver is
due to other group coverage.
*Takeover credit is available to groups at initial enrollment only. Ameritas: the group must have at least 10 eligible employees and provide proof of having 12 consecutive months of
prior coverage, with orthodontic coverage for orthodontic takeover credit. (12 months will be waived if 12 months proof is provided, no partial credit). Anthem Blue Cross: see plan
specific EOC for takeover credit information.
Voluntary
Employer
Sponsored
Provide Prior Coverage Information
(must complete to determine eligibility)
Yes No
Does your group currently have Group Dental Coverage?
If Yes, does the coverage include Orthodontic Coverage?
Yes No
Termination Date (MM/DD/YYYY)
Policy #
Carrier Name
Next
(to be offered with DeltaCare USA DHMO)
®
Next
$
OR
$
$
for Employee
for Dependents (no minimum)
for Employee with remainder to Dependents
(must be at least 50% of the lowest cost plan for each employee)
Enter the dollar amount to contribute for each employeeEnter the percentage to contribute for each employee
Based on:
% for Employee (minimum contribution is 50%)
% for Dependents (no minimum)
Highest - Cost Plan
Highest - Cost DHMO Plan
Highest - Cost PPO Plan
Plan Selected by Employee
Lowest - Cost Plan
Lowest - Cost DHMO Plan
Lowest - Cost PPO Plan
Specific Plan
Takeover Credit
Major Waiting Period
Ortho Min. Employees
Ortho Waiting Period
Takeover Credit
Major Waiting Period
Ortho Waiting Period
Ortho Min. Employees
Ameritas Delta Dental
5+ (Eligible)
12 Months
None
Available*
5+ (Eligible)
12 Months
None
None
Provide Counts (complete for Employer Sponsored option only) (write "0" if none)
Requirements for Orthodontic Coverage and Takeover Credit
(must be offered as core coverage, complete A-C)
Dental
Anthem Blue Cross
Ameritas
Anthem Blue Cross
Delta Dental
MetLife
Takeover Credit
Major Waiting Period
Ortho Waiting Period
Ortho Min. Employees
Takeover Credit
Major Waiting Period
Ortho Waiting Period
Ortho Min. Employees
MetLife
None
None
None
10+ (Eligible)
with 5+ (Enrolled)
None
None
None
10+ (Eligible)
with 5+ (Enrolled)
Employer Contribution (complete for Employer Sponsored option only) (select one option)
Takeover Credit
Major Waiting Period
Ortho Waiting Period
Ortho Min. Employees
Takeover Credit
Major Waiting Period
Ortho Waiting Period
N/A
12 Months
N/A
N/A
Available*
None
None
10+ (Eligible)
Takeover Credit
Major Waiting Period
Ortho Waiting Period
Ortho Min. Employees
Takeover Credit
Major Waiting Period
Ortho Waiting Period
Ortho Min. Employees
None
12 Months
12 Months
25+ (Eligible)
None
None
None
10+ (Enrolled)
CB 0210A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services
43422
Total number of
ELIGIBLE
employees
APPLYING
for coverage
Total number of COBRA beneficiaries APPLYING for coverage
Total number of ELIGIBLE employees WAIVING coverage due to
Other
GROUP
coverage
Other INDIVIDUAL coverage
OTHER reasons
STEP 4 - SELECT ADDITIONAL BENEFITS TO OFFER YOUR EMPLOYEES
Vision
(optional, complete A and B)
A. Select One Option
(complete for Employer Sponsored option only) (select one option)Employer Contribution
Option 1 - Percentage of Cost
Option 2 - Fixed Dollar Amount
Enter the percentage to contribute for each employee Enter the dollar amount to contribute for each employee
(must be at least 50% of the lowest cost plan for each employee)
Based on
Highest - Cost Plan
Plan Selected by Employee
Lowest - Cost Plan
Specific Plan
Provide Counts
(complete for Employer Sponsored option only) (write "0" if none)
Note:
eligible employees and dependents not
applying for coverage. Employees cannot
waive coverage if the employer’s
contribution is 100%, unless the waiver is
due to other group coverage.
Select a Flat amount for all employees
Employee Classification
(i.e. management, executive, etc.)
(3 of 5)
Next
Eyemed provided by Ameritas
VSP
B. Select One Vision Carrier
% for Dependents (no minimum)
% for Employee
(minimum contribution is 50%)
$ for Employee
$
for Dependents (no minimum)
OR
A. Select One Option
B. Select One Benefit Type
Chiropractic Only
Chiropractic & Acupuncture
Next
Employer Sponsored
Voluntary
(no employer contribution)
Chiropractic
(optional) offered by Landmark Healthplan (complete A and B)
Note:
This benefit must be employer sponsored, 100% employer paid, and 100% of eligible employees must enroll.
Eligible Employees Minimum Amount Maximum Amount
Guaranteed Issue Amounts are available as indicated in the table
ª
• Amounts must be in increments of $5,000 (calculated from the minimum amount)
• The highest amount may be no more than 2.5 X the lowest amount
• Employees must fall under specified classifications to qualify for specified amounts
11-25
2-10
26-199
(optional)
offered by Assurity Life
Life
Select One Option for Employee Life Amount
Option 1 - Flat Amount
Option 2 - Scheduled Amount
(select up to 4 classifications)
Life Amount
$
$
$
$
Amount
$
$
for Employee with remainder to Dependents
(complete employer contribution section below)
(no employer contribution)
(must be 100% employer paid)
Employer Sponsored
Voluntary
CB 0210A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services
200-500
$10,000
$10,000
$10,000
$10,000
$25,000
$50,000
$75,000
$150,000
43422
1. Participation. The employer or employee organization (as described in sections 3(4) or 3(5) of ERISA, respectively) named in the Master Application
(“Participating Employer”) hereby adopts as a participating employer the ChoiceBuilder Welfare Benefit Insurance Trust (the “Trust”), as set forth in the
instrument(s) creating such Trust (the “Trust Agreement”). Such action shall be effective on the date shown below with respect to the sub-trust first named
below that the Participating Employer is eligible to adopt in accordance with the terms of the Trust.
(a) Master Trust
(b) Industry Sub-Trust
(c) Single Employer Sub-Trust
(4 of 5)
ADDITIONAL TERMS & CONDITIONS TO THE CHOICEBUILDER WELFARE BENEFIT INSURANCE TRUST MASTER
APPLICATION
2. Ratification of Trust Agreement. Participating Employer hereby ratifies, accepts and agrees to be bound by all of the provisions of the Trust Agreement as
amended from time to time, a copy of which has been made available to it.
3.
Acceptance of Trustee and Administrator
. Participating Employer hereby accepts the trustee and administrator named in the Trust Agreement as the
trustee and administrator of the Trust (the “Trustee and Administrator”) with all of the rights, powers and responsibilities set forth in the Trust Agreement
and agrees to be bound by and ratifies the actions heretofore or hereafter taken by the Trustee and Administrator in accordance with the terms of the Trust
Agreement.
4. Trustee’s Action. Participating Employer acknowledges and agrees that its request to participate in the Trust pursuant to this Request for Participation
shall not be effective until accepted by the Trustee in accordance with the terms of the Trust Agreement. Trustee hereby represents that, before this Request
for Participation was entered into, all information described in Paragraph 9 hereof was provided to the fiduciary of the Participating Employer with the
authority to enter the Participating Employer into the Trust (the
“Responsible Plan Fiduciary
).
5. Benefits Subject to Provisions of Insurance Policies. Participating Employer agrees to be bound by the terms and conditions of the Trust Policies (as
defined in the Trust Agreement) under which its employees become covered and agrees to pay all premiums required by the provisions of the Trust Policies
for the coverages it purchases. Participating Employer understands that the insurance coverages it elects to purchase hereunder may terminate or lapse if
such premiums are not paid when required by the provisions of the Trust Policies.
6.
Assignment to Applicable Trust
. Participating Employer agrees that the Trustee may assign or cause it to be assigned to any sub-trust under the Trust for
which the Participating Employer is eligible at the time of this request. The Participating Employer acknowledges that it has indicated its proper Standard
Industry Classification Code below to facilitate such assignment and that the Trustee may assign or cause it to be assigned to a different sub-trust under the
Trust for which it becomes eligible in the future, should the Trustee deem this advisable.
7. Establishment of Plan; Designation of Claims Administrator. Participating Employer agrees that, by adopting this Trust, it is establishing an employee
welfare benefit plan (the
“Plan”
) in accordance with the Employee Retirement Security Act of 1974, as amended (
"ERISA"
) to provide its eligible employees
with the insurance benefits provided by the Policies. Participating Employer further agrees that it will communicate the terms of the Plan to all eligible
employees, and will maintain such Plan in full force and effect so long as any employee remains eligible for such insurance benefits. Participating Employer
hereby designates, in accordance with Section 503 of ERISA, the Carrier issuing a Policy as the named fiduciary under the Plan with complete and
discretionary authority to review all denied claims for insurance benefits under such Policy and to construe disputed or doubtful Policy terms with respect to
such insurance benefits and that such Carrier shall be deemed to properly exercise such authority unless it abuses its discretion by acting arbitrarily and
capriciously.
8. Limitations on Participating Employer’s Rights and Responsibilities under the Trust. Participating Employer’s sole responsibility under the Trust is to adopt
it as set forth in this Request for Participation. Upon acceptance of its adoption by the Trustee, Participating Employer shall have no further rights, duties or
responsibilities under the Trust, except to the extent otherwise provided therein.
9. Disclosure of Fees and Conflicts of Interest. Notwithstanding anything herein to the contrary, this Request for Participation shall not become effective until
the Trustee, to the best of its knowledge, provides or causes to be provided to the Responsible Plan Fiduciary the following disclosures or such other
disclosures as may be required by ERISA:
(continued on next page)
(a) All services to be provided by the Trustee or any of its affiliates (collectively, the Service Providers”) pursuant to the Trust Agreement, this Request
for Participation and any other agreements or arrangements related to the provision of benefits by the Trust or Policies (collectively, the Service
Agreements”
), the compensation or fees (including, gifts, awards, or trips received, or to be received, from any source on account of the Service
Provider’s position with the Plan) for such services, and the manner of receipt of such compensation. Such disclosure shall provide a description of the
manner of receipt of compensation or fees and shall state whether the Service Providers will bill the Participating Employer, deduct fees directly from the
Plan accounts, or reflect a charge against the Plan investment. Such disclosure will also describe how any prepaid fees will be calculated and refunded
when Participating Employer withdraws from the Plan.
(b) Whether any Service Provider will provide any services to the Plan as a fiduciary either within the meaning of Section 3(21) of ERISA or under the
Investment Advisers Act of 1940.
(c) Whether any Service Provider expects to participate in, or otherwise acquire a financial or other interest in, any transaction to be entered into by the
Plan and, if so, a description of the transaction and the Service Provider’s participation or interest therein.
(d) Whether any Service Provider has any material financial, referral, or other relationship or arrangement with a money manager, broker, other client of
the Service Provider, other service provider to the Plan, or any other entity that creates or may create a conflict of interest for the Service Provider in
performing services to the Plan and, if so, a description of such relationship or arrangement.
(e) Whether any Service Provider will be able to affect its own or another Service Provider’s compensation or fees, from whatever source, without the
prior approval of an independent fiduciary of the Plan, in connection with the provision of services to the Plan (for example, as a result of incentive,
performance-based, float, or other contingent compensation) and, if so, a description of the nature of such compensation.
(f) Whether any Service Provider has any policies or procedures that (i) address actual or potential conflicts of interest or (ii) are designed to prevent
either compensation or fees or any other business ventures or relations that may be entered into between the Plan and a Service Provider, from
adversely affecting a Service Provider’s ability to provide services under the Service Agreements, and, if so, an explanation of these policies or
procedures and how they address such conflicts of interest or prevent an adverse effect on the provision of services.
The Trustee shall disclose or cause to be disclosed to the Responsible Plan Fiduciary any material change to the information disclosed above not later than
30 days from the date on which the Service Provider acquires knowledge of the material change. The Trustee shall also disclose or cause to be disclosed all
information related to the Service Agreements and any compensation or fees received there under that is requested by the Responsible Plan Fiduciary or
administrator of the Plan in order to comply with the reporting and disclosure requirements of Title I of ERISA and the regulations, forms, and schedules
issued there under.
CB 0210A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services
®
43422
(5 of 5)
STATEMENT OF COMPLIANCE
I hereby certify that all the information contained in the employer application is true and correct to the best of my knowledge. I have read and
understand the following statements and confirm that my group complies with all the rules and regulations of the ChoiceBuilder Program. I
understand that no coverage will become effective until notified by the ChoiceBuilder Underwriting Department.
• Our Home Office is located in California
• ChoiceBuilder coverage will be offered to all eligible employees on a uniform basis
I DECLARE UNDER THE PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ABOVE STATEMENTS ARE TRUE
AND CORRECT.
I understand that ChoiceBuilder coverage will be administered under the laws of California for all enrollees.
I understand that once ChoiceBuilder coverage is approved, group policy changes cannot be implemented until the next renewal period. These changes shall include, but are not
limited to COBRA provisions, new hire waiting period, minimum hours worked per week, and premium contribution amounts.
I understand that once membership information is transmitted to the elected health plans, our group coverage effective date cannot be changed nor can our coverage be terminated
until after the first month of coverage.
I understand that no alterations can be made to this section and that it must be signed exactly as stated.
I understand that the above statements are subject to audit at any time.
I understand that the above qualifications must be maintained in order for my group to continue coverage through ChoiceBuilder.
I agree to provide ChoiceBuilder with any and all information necessary to prove the above statements.
I understand that if I am unable to provide the requested information, all ChoiceBuilder benefits will terminate 15 days following notice of termination and employees will be held
responsible for all services and charges incurred through ChoiceBuilder program providers.
I understand that any persons, business, or health plan that suffers a loss because of false declarations contained in this employer application may have cause to bring civil action
against our company to recover their losses.
I understand that premium payments are to be received by ChoiceBuilder by the statement due date.
I agree and understand that if the contributory status or participation percentages change that ChoiceBuilder reserves the right to non-renew or adjust premiums accordingly.
Company Name
Print Name
Signature of Broker of Record
Owner/Partner Signature
BROKER/AGENT ACKNOWLEDGEMENT
General Agent/PPGA Name
Broker Name
Commissions payable to
% Commission if split
Broker Signature
I certify that the employer applying for coverage through the ChoiceBuilder program has met all applying participation requirements
Agent/Producer/Broker Attestation – To be completed by the agent/broker
Enrollment Quote Number
(if applicable)
(must include version number)
(please print) Must be broker name - not agency
% Commission if split
Commissions payable to
Co-Broker Name
(please print)
Co-Broker Signature
Phone # (XXX) XXX-XXXX
Date (MM/DD/YYYY) Date (MM/DD/YYYY)
Date (MM/DD/YYYY)
Fax # (XXX) XXX-XXXX Phone # (XXX) XXX-XXXX Fax # (XXX) XXX-XXXX
1. To the best of my knowledge, the information on this application is complete and accurate.
2. I am not aware of any information not disclosed by the client in this application that may have bearing on this risk.
3. I have not completed any of the information contained in the application except with the permission of the applicant and as noted by my initials and date on the application.
4. I have not signed any of the applications for an employer representative or individual applicant. If after submission of this application, I request any additions or changes to any of the
above information, I will do so only with the written consent of the applicant, and I authorize ChoiceBuilder to attribute such additions or changes to me.
5. I have advised the employer, in easy-to-understand language, that a failure to provide complete and accurate information may result in a loss of coverage retroactive to the effective
date of coverage or re-rating of the employer's premium retroactive to the coverage effective date and that coverage shall not be effective until ChoiceBuilder reviews and approves the
application and the employer receives a written notice from ChoiceBuilder. The employer understood my explanation.
6. I am the appointed agent/broker and am receiving commissions for the submission of this client. No portion of my commission payments from ChoiceBuilder shall be paid to an
agent/producer/broker not appointed/approved by ChoiceBuilder.
7. I have advised the client not to terminate any existing coverage until receiving written notification from ChoiceBuilder that the coverage being applied for by this application is
accepted.
8. By providing your "wet or electronic" signature below, you acknowledge that such signature is valid and binding.
9. I understand that if any portion of this statement signed by me is willfully false, I may be subject to civil penalties as authorized under California Health and Safety Code Section
1389.8 and Insurance Code Section 10119.3: if I willfully state as true any material fact that I know to be false, I shall, in addition to any applicable penalties or remedies available under
current law, be subject to a civil penalty of up to $10,000.
Print Name Date (MM/DD/YYYY)
CB 0210A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services
®
43422