Fillable Form 800: - Employer Application A Employer Information (Dickerson Insurance Services)

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Form 800: - Employer Application A Employer Information (Dickerson Insurance Services)

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(1 of 6)
Invoice Option
E-mail Only Paper Only Both
Enrollment & Eligibility Information
City ZIP Code
Billing Address Suite/Unit #
State
Check if Residence
Employer Information
CA Federal Tax ID # (9 digits) - NOT Social Security #
DBA Name (Doing Business As) Exact Nature of Business
Owner/President Name
Contact Name
Contact Job Title
Contact E-mail Address
City ZIP Code
Street Address (if different) (no P.O. Box) Suite/Unit #
State
CA
Check if Residence
County
County
Worker's Comp Carrier Name
Company Structure
(not broker or agency name)
Note: Workers’ Compensation Coverage must be effective on or prior to the effective date requested with CaliforniaChoice
100% family-related running business out of home (does not include domestic partners; family members must reside at the same residence)
We are not covered by Workers’ Compensation coverage due to legal exemption under the following checked condition
Date Business Started (MM/DD/YYYY)
Contact Phone # (XXX) XXX-XXXX Contact Fax # (XXX) XXX-XXXX
A) Union B) Part-time C) Seasonal D) Temporary E) Terminated
13. Total number of ineligible employees in each of the following categories (write “0” if none)
14. How many of the employees (including owners) enrolling are related by blood or marriage?
A
B
-
Legal Company Name
Owner/President Email Address
Corporation
S Corporation
Sole Proprietor
Partnership
LLC
Other
Yes No
3. Have you employed 20 or more employees during at
least 50% of the preceding calendar year? (COBRA)
7. Does your group currently have
group medical coverage?
Yes
No
Carrier Name
Policy #
8. Eligible employees must work the following number of hours to qualify
20+ hours a week 30+ hours a week
9. Waiting Period for new employees is first day of the month following
Date of Hire 30 days 60 Days (NOT to exceed 90 days)
10. Waiting period applies to
Future employees (hired after the effective date)
Current and future employees (Current=hired on or prior to effective date)
Total # of COBRA Enrollees
Termination Date
(MM/DD/YYYY)
# in Waiting Period
11. Total number of employees on payroll regardless of hours worked
Total number of active eligible
employees on payroll
Total number of eligible employees applying
for medical
(including owners, seasonal, etc.)
(including owners, seasonal, etc.)
(including owners, seasonal, etc.)
12. Number of employees waiving due to
A) Other Group Coverage
B) Other Individual Coverage
2. How many pay periods per year? (Will be shown on Employee Enrollment Worksheets)
12 24 26 48 52
6. Average number of total employees (full-time, part-time and seasonal) in the preceding year?
5. Have you employed 20 or more employees for 20 or more weeks during the current or preceding year? (TEFRA)
Yes No
Yes No
4. If you answered YES to question #3, do you want your COBRA participants on your bill?
(If yes, you must complete the “Group COBRA Direct Billing” contract)
721 South Parker, Suite 200, Orange, CA 92868
(
800
)
558-8003 • www.calchoice.com
• Please complete using black ink
• Return signed and completed application - and those of employees - to your broker
Employer Application
(For CaliforniaChoice use only)
Group #
1. Requested Effective Date (MM/DD/YYYY)
SIC Code
(Enter
below)
Add Broker of Record as an
Authorized Group Contact
®
CC 0201 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
33185
Premium Contribution Method
(2 of 6)
OPTION 1
PERCENTAGE OF COST
STEP 1: Enter the percentage amount you will contribute toward
%
(50% minimum)
%
(write 0 if none)
STEP 2:
Apply contribution toward A*, B*, C*, D, E, F or G. (*If no HMO plan available to Employee, contribution will be based on lowest cost PPO plan)
A. Lowest cost HMO within the Metal Tier(s) selected.
Dependent Premium
C.
HMO
Lowest cost benefit plan in HMO:
(select one benefit level from the
Metal Tier(s) selected in Section C)
Lowest cost PPO within the Metal Tier(s) selected.
F.
G. Any HMO, EPO or PPO plan selected by employee.
B.
HMO
and EPO
Specific
Health Plan:
(select one
benefit plan
from the Metal
Tier(s) selected
in Section C)
E.
PPO
Lowest cost benefit plan in PPO:
(select one benefit level from the
Metal Tier(s) selected in Section C)
D.
PPO
Specific Health Plan:
(select one benefit plan from the
Metal Tier(s) selected in Section C)
Metal Tie
r
Select ONE Metal Tier option
to offer to your employees:
Single Choice
Double Choice
BRONZE SILVER GOLD PLATINUM
BRONZE/SILVER SILVER/GOLD GOLD/PLATINUM
SILVER/GOLD/PLATINUM
BRONZE/SILVER/GOLD
BRONZE/SILVER/GOLD/PLATINUM
C
Employee Premium
D
(CONTINUED ON NEXT PAGE)
PLATINU
M
BRONZ
E
SILVER GOLD
HM
O
HMO A
HMO B
HMO C
HMO A
HMO B
HMO C
HMO A
HMO B
HMO C
HMO A
HMO B
HMO C
HMO D
HMO D
HMO E
HMO D
HMO E
CHOOSE ONLY ONE OPTION BELOW
Triple Choice
CC 0201A 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
HMO F
*
HSA Qualified
High Deductible
Plan
Total Choice
HMO H HMO G
HMO E
HMO G
HMO H
HMO I
HMO J
HMO K
HMO F
HMO G
HMO H
PLATINUM
SILVE
R
BRONZ
E
GOLD
EPO A
HMO A
EPO A
HMO A
HMO A
HMO C
HMO C
HMO B
HMO A
HMO A
HMO A
HMO C*
HMO B
HMO C
HMO C
HMO B
HMO A
HMO A
HMO B*
HMO A
HMO B*
HMO B
HMO C*
EPO B*
HMO A
HMO B
HMO A
HMO B
HMO B
HMO A
HMO B
HMO E
HMO A
HMO B
HMO F
HMO A
HMO D
HMO B
HMO C*
HMO A
HMO B
HMO C*
HMO A
HMO B
HMO C
HMO D*
HMO A
HMO D*
Anthem
Blue Cross
Health
Net
Kaiser
Permanente
Sharp
Sutter
Health Plus
UnitedHealthcare
Western
Health
HMO C
HMO B
HMO A
HMO D
HMO B
HMO A
HMO B
HMO A
HMO A
HMO C
HMO D
HMO D
HMO E
EPO C
EPO A*
EPO B
EPO A*
EPO B
EPO A
EPO B
EPO A
EPO B
Oscar
HMO A
EPO C
EPO D
HMO B
HMO B
HMO B
HMO E
HMO C
HMO C
HMO B
HMO F
EPO C
EPO D
HMO E
HMO F
HMO G
HMO E
HMO F
HMO G
HMO H
HMO I
HMO J
HMO K
HMO D
HMO E
HMO C
BRONZE SILVER GOLD
PPO D
PPO C
PPO B
PPO A
PPO B
PPO A
A
nthem Blue Cross PPO
PPO B
PPO
A
PPO C
PPO E
BRONZE SILVER GOLD
PPO D
PPO C
PPO B
PPO A
PPO B
PPO A
A
nthem Blue Cross PPO
PPO B*
PPO A*
PPO C
PPO E
HSA Qualified High Deductible Plan
*
33185
(3 of 6)
OPTION 2
EMPLO
ER FIXED DOLLAR AMOUNT
Enter the dollar amount(s) you will contribute toward any plan selected by the employee. (Employer must pay for at least 50% of each Employee's
lowest cost premium)
$
$
for Dependents (write 0 if none)
for Employee
OR
$
Combined amount for
Em
p
lo
y
ee and De
p
endents
OPTION 3
EMPLOYEE
FIXED DOLLAR AMOUNT
STEP 1: Enter the dollar amount(s) the employee will contribute toward
STEP 2:
Apply contribution toward A or B
Employee Cost
$
$
A
dditional for Spouse
A
dditional for child(ren)
$
$
A
dditional for Family
D
Premium Contribution Method (Cont.)
Please be advised that Employee Enrollment Application forms are available in the following languages: Spanish, Chinese, Korean, Tagalog, Vietnamese
and Russian - please contact your broker or CaliforniaChoice . Some translations in these languages are also available to your employees on an on-going
basis as well as interpretation services in 150 different languages. CaliforniaChoice would be glad to give you copies of the Employee Enrollment
A
pplication Form in the “threshold languages” of the Plan(s) your employees select. Please contact us or your broker to receive these.
If you do not make an additional contribution for dependents enter "NA"
A.
B.
PPO
HMO
and EPO
Specific
Health Plan:
(select one
benefit plan
from the Metal
Tier(s) selected
in Section C)
CC 0201B 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
®
HSA Qualified
High Deductible
Plan
*
Specific Health Plan:
(select one benefit plan from the
Metal Tier(s) selected in Section C)
PLATINUM
SILVE
R
BRONZ
E
GOLD
EPO A
HMO A
EPO A
HMO A
HMO A
HMO C
HMO C
HMO B
HMO A
HMO A
HMO A
HMO C*
HMO B
HMO C
HMO C
HMO B
HMO A
HMO A
HMO B*
HMO A
HMO B*
HMO B
HMO C*
EPO B*
HMO A
HMO B
HMO A
HMO B
HMO B
HMO A
HMO B
HMO E
HMO A
HMO B
HMO F
HMO A
HMO D
HMO B
HMO C*
HMO A
HMO B
HMO C*
HMO A
HMO B
HMO C
HMO D*
HMO A
HMO D*
Anthem
Blue Cross
Health
Net
Kaiser
Permanente
Sharp
Sutter
Health Plus
UnitedHealthcare
Western
Health
HMO C
HMO B
HMO A
HMO D
HMO B
HMO A
HMO B
HMO A
HMO A
HMO C
HMO D
HMO D
HMO E
EPO C
EPO A*
EPO B
EPO A*
EPO B
EPO A
EPO B
EPO A
EPO B
Oscar
HMO A
EPO C
EPO D
HMO B
HMO B
HMO B
HMO E
HMO C
HMO C
HMO B
HMO F
EPO C
EPO D
HMO E
HMO F
HMO G
HMO E
HMO F
HMO G
HMO H
HMO I
HMO J
HMO K
HMO D
HMO E
HMO C
HMO H
HMO G
BRONZ
E
SILVE
R
GOLD
PPO D
PPO C
PPO B
PPO A
PPO B
PPO A
A
nthem Blue Cross PP
O
PPO B*
PPO A*
PPO C
PPO E
HSA Qualified High Deductible Plan
*
33185
(4 of 6)
Statement of Compliance
E
I understand that no coverage will become effective until notified by the CaliforniaChoice Underwriting Department. I
hereby certify that all information contained in the employer and employee applications are true and correct to the best
of my knowledge.
I understand that CaliforniaChoice will not consider my group approved until the funds have been received for our
first month's premium payment. If such funds are not received or cannot be processed, my group will NOT be
considered approved and will be terminated as of the original requested effective date. If such a termination is made,
any expenses that may have been incurred due to utilization by our employees of health care services offered by a
CaliforniaChoice plan or carrier will not be the responsibility of CaliforniaChoice, the health plan or carrier.
I understand that no alterations can be made to this section and that it must be signed exactly as stated. I have read
and understand the following statements and confirm that my group complies with all the rules and regulations of the
CaliforniaChoice Pro
g
ram.
• Our Home Office is located in California.
• A majority (51+%) of our eligible employees reside in California.
• I will maintain all participation requirements including all eligible employees (as noted in the CaliforniaChoice Underwriting
Guidelines).
• CaliforniaChoice coverage will be offered to all eligible employees on a uniform basis.
• All employees enrolling are currently working the minimum number of hours per week to be considered eligible (as noted in
Section B) to enroll for CaliforniaChoice coverage.
I understand that once CaliforniaChoice coverage is approved, group policy changes cannot be implemented until the next
Renewal (Anniversary Date). These changes shall include, but are not limited to COBRA provisions, minimum hours worked
per week, and premium contribution amounts.
I understand the plan documents will determine the contractual provisions, including procedures, exclusions and limitations
relating to the plan and will govern in the event they conflict with any benefits comparison, summary or other description of the
plan.
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
CaliforniaChoice.
I agree to provide CaliforniaChoice with any and all information necessary to prove the above statements.
I understand that if I am unable to provide the requested information, all CaliforniaChoice benefits will terminate 15 days
following notice of termination, and employees will be held responsible for all services and charges incurred through
CaliforniaChoice 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 CaliforniaChoice by the statement due date.
I understand that all California Applicants will be subject to Binding Arbitration (see Employee Application).
I understand that if I have elected to add my Broker of Record as an Authorized Group Contact, my Broker of Record will have
the ability to make changes on behalf of my group, which may result in a change in premium(s) and/or cancellation of
covera
g
e
(
s
)
.
Owner/Partner Signature
Signature of Broker of Record
Print Name
Print Name
Date (MM/DD/YYYY)
Date (MM/DD/YYYY)
Company Name
(continued on next page)
CC 0201C 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
®
33185
To be completed by BROKER:
General Agent/PPGA Name (if applicable)
Broker Name (please print) Must be broker name - not agency
Commissions payable to
Co-broker Name (please print)
Commissions payable to
Phone # (XXX) XXX-XXXX Fax # (XXX) XXX-XXXX Phone # (XXX) XXX-XXXX Fax # (XXX) XXX-XXXX
% Commission if split % Commission if split
(5 of 6)
Statement of Compliance
(
continued
)
E
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 CaliforniaChoice 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 CaliforniaChoice reviews and
approves the application and the employer receives a written notice from CaliforniaChoice. 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 CaliforniaChoice shall be paid to an agent/producer/broker not appointed/approved by
CaliforniaChoice.
7. I have advised the client not to terminate any existing coverage until receiving written notification from CaliforniaChoice 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.
I certify that the employer applying for coverage through the CaliforniaChoice Program has met all participation
requirements. Agent/Producer/Broker Attestation - To be completed by the agent/broker
Broker Signature
Date (MM/DD/YYYY)
Co-Broker Signature
Date (MM/DD/YYYY)
CC 0201D 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
®
33185
Groups electing Ameritas PPO plans with 10 or more
employees qualify for takeover benefits by submitting
the following:
1) Group’s most recent prior dental billing statement;
2) Statement from 12 months prior to effective date;
3) and 12 months prior showing Ortho for Ortho
takeover
(6 of 6)
Optional Benefits Application
Company Name
Dental Insurance
F
When electing dental coverage, the undersigned employer hereby applies for membership in the Bankers Life Nebraska Preferred Trust.
Ste
p
1:
Select one
p
lan offerin
g
*Ameritas PPO plans with Ortho
are only available to groups with
5 or more eligible employees
Ste
p
2:
Complete numbers 1-6 below for buy up dental plans only
A
ll buy-up dental plans: MetLife DHMO, SmileSaver DHMO and Ameritas PPO plans WITHOUT Ortho
A
ll buy-up dental plans: MetLife DHMO, SmileSaver DHMO and Ameritas PPO* plans WITH Ortho
A
ll voluntary dental plans: MetLife DHMO, SmileSaver DHMO and Ameritas PPO plans WITHOUT Ortho
(Do not complete for voluntary dental plans)
1. Total number of employees applying for dental coverage
2. Total number of COBRA eligibles applying for dental coverage
3. Percentage of employee-only premium paid by Employer
4. Percentage of dependent premium paid by Employer
5. Employer contribution is based on plan
6. Does your group currently have dental?
1000 3000 3500 4000 5000
MET100 MET185
% (Employer must
p
ay a minimum of 50%)
% (write 0 if none)
Yes No
If yes, carrier name
Voluntary Vision
G
Check this box if you would like to offer Voluntary Vision to your employees. Employees are responsible for 100% of this cost if they enroll in this coverage.
ChiroPlus
H
Landmark Healthplan, Inc.
Chiropractic Only Chiropractic & Acupuncture
CHOOSE ONE
PLAN ONLY
Life Insurance
I
Assurity Life Insurance Company
OPTION 1: Flat Amount
Select a Flat amount for
all employees
1.
A
mount
2. # of eligible
employees
OPTION 2: Scheduled Amount
Select up to 4 amounts with the highest
being NO MORE THAN 2.5 X the lowest.
(amounts must be in increments of $5,000)
Life Amount
Section 125 — Premium Only Plan
J
CONEXIS Benefit Administrators (a division of WageWorks)
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 in the P.O.P.
IMPORTANT: Read the information provided in the CaliforniaChoice Employer Optional Benefits Guide pertaining to the Section 125 Premium Only Plan and the tax consequences.
Name of Company President, Principal, or Partners Name of Corporate Secretary (if applicable)
5. Company Structure
Corporation
S Corporation
Sole Proprietorship
Partnership
LLC
Other
State of Incorporation or Domicile (if applicable)
Plan Number (usually 501)
(If not indicated, 501 will be used)
6. Premium payments may be elected for
7. Last day of first Plan year
(If not indicated, last day of medical plan year will be used)
Usually 12 months after the effective date of coverage;
subsequent plan years will be the 12 month period following this date.
Employee Classification*
(i.e. management, executives, etc.)
Employer Signature Print Name
$
$
$
$
(MM/DD/YYYY)
Date (MM/DD/YYYY)
†
When electing vision coverage, the undersigned employer hereby applies for membership in the Bankers Life Nebraska Preferred Trust. Provided by Ameritas.
†
$
4.
2. 3.1.
100% of all eligible employees (whether enrolling or waiving
medical) must enroll for life coverage.
◄CHOOSE ONE OPTION ONLY►
Guaranteed Issue Amounts available for both Options
Eligible Employees
Maximum
Amounts in between available in increments of $5,000
*Employees must fall under classification to
qualify for specified amount
Minimum
1-10
11-25
26-50
51-100
$10,000
$10,000
$10,000
$10,000
$25,000
$50,000
$75,000
$100,000
EyeMed /VSP
††
MetLife DHMO/SmileSaver DHMO/Ameritas (PPO)
†
SM
Medical
Dental
Vision
Other
CC 0201E 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
®
A
ll voluntary dental plans: MetLife DHMO, SmileSaver DHMO and Ameritas PPO* plans WITH Ortho
SmileSaver DHMO Ameritas PPO
3000
(Check one box only)
MetLife DHMO
33185
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Form 800: - Employer Application A Employer Information (Dickerson Insurance Services)

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Completed 1 June 2021

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