BASE® ERISA Wrap Plan Application

In order to properly set up your BASE® ERISA Wrap Plan, you need to complete the following electronic application. Please make sure to read all of the instructions carefully. All fields indicated with an asterisk (*) are required. If at any time you need to save the application and come back to it later, you can go to the bottom and click on "Save". When clicking "Save" it would be best to copy and paste the link provided into an email to yourself or another party.

Once you have completed a section you will see a check mark next to the heading for that section. Once you have completed all three sections plus any benefit components a "Submit" button will appear to the right of the "Save" button located at the bottom of the page. You will want to click the "Submit" button, which will securely submit your application to BASE®.

Should you have any questions, please feel free to call 1-800-309-8012 to speak with a BASE® representative.

Section I

Plan Sponsor Information

Business Entity Information

(please specify)

Primary Contact at Employer

Plan Information

This is:
A New Plan
An Amendment and Restatement of an Existing Plan

Welfare plan number begin with 501 and proceed consecutively. So, the second welfare plan of an employer would be 502, followed by 503, ect. A plan number can never be used more than once by an employer.

Effective Date of Plan cannot be set earlier that the 1st of the month in which your payment is received by Base.

Plan Year dates:

Starts On: Ends On:

When does your Group Healthcare renew? BASE will contact you annually prior to this date to verify any benefit changes.

Section II

Types of Benefit Plans Offered

Which benefits do you wish to include in the SPD/Plan Document? (Check ALL Benefit Plans that apply)

Medical Plan
 
Fully Insured
Self-Insured
Dental Plan
 
Fully Insured
Self-Insured
Dependent Care Reimbursement Account (DCRA) Plan
Health Care Flexible Spending Account
Health Reimbursement Account (HRA)
Health Savings Account (HSA) Contributions
Life Insurance Plan
 
Fully Insured
Self-Insured
Voluntary Life Insurance Plan
 
Fully Insured
Self-Insured
Long-Term Disability Plan
 
Fully Insured
Self-Insured
Short-Term Disability Plan
 
Fully Insured
Self-Insured
Vision Plan
 
Fully Insured
Self-Insured
Other Employer Sponsored Insurance Policies
 
Fully Insured
Self-Insured
Premium Only Plan / Pre-Tax Contributions

Other Participating Employers

Are other Employers participating in this plan?
Yes
No

Section III

Eligibility

This section is used to establish the general eligibility criteria for benefit plans offered by the organization. Please note that you can enter specific eligibility requirements for each component benefit plan.

How many hours per week must an Employee work to be eligible for coverage?*

NOTE: The hours cannot exceed 30 hours according to the Affordable Care Act.

For employers subject to the "pay or play" provisions under Health Care Reform, do you want to specify the measurement method for determining full-time status (i.e., monthly vs. look-back)?*

For employers NOT subject to Pay or Play (less than 50 full-time equivalent employees as defined by the PPACA), select "Not Applicable – The employer is not subject to "pay or play."

No (basic language regarding compliance with the Affordable Care Act will be included in the wrap documents)
Yes - The look-back measurement method is used for the following categories of Employees:
All Employees
Salaried Employees
Hourly Employees
Employees whose primary place of employment is in
Collectively bargained Employees that are covered by the same collective bargaining agreement
Collectively bargained Employees that are covered by separate collective bargaining agreement(s) named
Non-collectively bargained Employees
Yes - The monthly measurement method is used for the following categories of Employees:
All Employees
Salaried Employees
Hourly Employees
Employees whose primary place of employment is in
Collectively bargained Employees that are covered by the same collective bargaining agreement
Collectively bargained Employees that are covered by separate collective bargaining agreement(s) named
Non-collectively bargained Employees
Not applicable - The employer is not subject to "pay or play"

Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Domestic Partner
Other:
Are there any classes of Employees that are excluded? *

Please be specific. For example, you must specify the number of months for Seasonal Workers not to exceed 8 months in a calendar year.

Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements? *
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin? *
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate? *
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

Component Benefit Plan Information - Medical Plan

(Enter description or name of insurance plan from the Certificate of Coverage)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Grandfathered Plan

Is the health insurance plan a "grandfathered plan" under PPACA?*
Yes
No / Not Applicable

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are the same as entered under the 'General Plan Information'
The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
The eligibility requirements for this benefit are different and I need to enter them
How many hours per week must an Employee work to be eligible for coverage? *
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Domestic Partner
Other:
Are there any classes of Employees that are excluded? *
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

Approximate number of employees participating in this health insurance plan*

The employer offers another medical plan? 

Component Benefit Plan Information - Medical Plan 2

(Enter description or name of insurance plan from the Certificate of Coverage)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Grandfathered Plan

Is the health insurance plan a "grandfathered plan" under PPACA?*
Yes
No / Not Applicable

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are the same as entered under the 'General Plan Information'
The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
The eligibility requirements for this benefit are different and I need to enter them
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Domestic Partner
Other:
Are there any classes of Employees that are excluded? *
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

Approximate number of employees participating in this health insurance plan* 

The employer offers another medical plan? 

Component Benefit Plan Information - Medical Plan 3

(Enter description or name of insurance plan from the Certificate of Coverage)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Grandfathered Plan

Is the health insurance plan a "grandfathered plan" under PPACA?*
Yes
No / Not Applicable

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are the same as entered under the 'General Plan Information'
The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
The eligibility requirements for this benefit are different and I need to enter them
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Domestic Partner
Other:
Are there any classes of Employees that are excluded? *
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

Approximate number of employees participating in this health insurance plan* 

Component Benefit Plan Information - Dental Plan

(Enter description or name of insurance plan from the Certificate of Coverage)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are the same as entered under the 'General Plan Information'
The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
The eligibility requirements for this benefit are different and I need to enter them
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Domestic Partner
Other:
Are there any classes of Employees that are excluded?*
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

The employer offers another dental plan? 

Component Benefit Plan Information - Dental Plan 2

(Enter description or name of insurance plan from the Certificate of Coverage)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are the same as entered under the 'General Plan Information'
The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
The eligibility requirements for this benefit are different and I need to enter them
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Domestic Partner
Other:
Are there any classes of Employees that are excluded?*
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

Component Benefit Plan Information - Dependent Care Reimbursement Account (DCRA) Plan

(Enter description or name from Certificate, e.g. Group Medical Plan, Dental Plan, etc.)

Component Benefit Plan Information - Health Care Flexible Spending Account

(Enter description or name from Certificate, e.g. Group Medical Plan, Dental Plan, etc.)

Component Benefit Plan Information - Health Reimbursement Account

(Enter description or name from Certificate, e.g. Group Medical Plan, Dental Plan, etc.)

Component Benefit Plan Information - Health Savings Account (HSA) Contributions

Component Benefit Plan Information - Life Insurance Plan

(Enter description or name of insurance plan from the Certificate of Coverage)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
Customize the eligibility requirements for this benefit
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Other:
Are there any classes of Employees that are excluded?*
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

Component Benefit Plan Information - Voluntary Life Insurance Plan

(Enter description or name of insurance plan from the Certificate of Coverage)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Plan Contributions

Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
Customize the eligibility requirements for this benefit
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Other:
Are there any classes of Employees that are excluded?*
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

Component Benefit Plan Information - Long-Term Disability Plan

(Enter description or name of insurance plan from the Certificate of Coverage)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
Customize the eligibility requirements for this benefit
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee?
Other:
Are there any classes of Employees that are excluded?*
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

Component Benefit Plan Information - Short-Term Disability Plan

(Enter description or name of insurance plan from the Certificate of Coverage)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
Customize the eligibility requirements for this benefit
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee?
Other:
Are there any classes of Employees that are excluded?*
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

Component Benefit Plan Information - Vision Plan

(Enter description or name of insurance plan from the Certificate of Coverage)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are the same as entered under the 'General Plan Information'
The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
The eligibility requirements for this benefit are different and I need to enter them
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Domestic Partner
Other:
Are there any classes of Employees that are excluded?*
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

Component Benefit Plan Information - Other Employer Sponsored Insurance Policies

(Enter description or name from Certificate, e.g. Group Medical Plan, Dental Plan, etc.)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are the same as entered under the 'General Plan Information'
The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
The eligibility requirements for this benefit are different and I need to enter them
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Domestic Partner
Other:
Are there any classes of Employees that are excluded?*
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

The employer offers another "Other Employer Sponsored Insurance Policies" plan? 

Component Benefit Plan Information - Other Employer Sponsored Insurance Policies 2

(Enter description or name from Certificate, e.g. Group Medical Plan, Dental Plan, etc.)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are the same as entered under the 'General Plan Information'
The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
The eligibility requirements for this benefit are different and I need to enter them
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Domestic Partner
Other:
Are there any classes of Employees that are excluded?*
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .

The employer offers another "Other Employer Sponsored Insurance Policies" plan? 

Component Benefit Plan Information - Other Employer Sponsored Insurance Policies 3

(Enter description or name from Certificate, e.g. Group Medical Plan, Dental Plan, etc.)

Carrier & Plan Administrator Information

Plan Administered by*
Carrier (for Fully Insured Plan)
Third Party Administrator (for Self-Insured Plan)

Plan Contributions

Does the employer pay 100% of the premiums for this insurance?*
Yes
No
Do your employees take a payroll deduction, on a pre-tax basis, to pay their portion of the premiums?*
Yes
No

Eligibility

Please select one of the following choices:*

The eligibility requirements for this benefit are the same as entered under the 'General Plan Information'
The eligibility requirements for this benefit are contained in the benefit booklets and certificates, provider contracts and benefit descriptions
The eligibility requirements for this benefit are different and I need to enter them
How many hours per week must an Employee work to be eligible for coverage?*
Which Employees are generally eligible to participate? (Check only one)*
All Employees
Salaried Employees Only
Hourly Employees Only
Others:
Who is eligible for coverage other than the Employee? (Check ALL that apply)
Spouse
Dependent/Child
Domestic Partner
Other:
Are there any classes of Employees that are excluded?*
Not applicable
Yes (enter class(es) of Employees excluded and separate multiple classes using commas)
What are the waiting period requirements?*
No waiting period requirements
Days:
Other: An Employee is eligible to participate .
When does Plan coverage begin?*
On the date of hire
On the day after the end of the waiting period
On the first day of the calendar month after the end of the waiting period
Other: Plan coverage begins .
When does coverage terminate?*
The day the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
At the end of the month the Employee terminates employment or is no longer an eligible Employee under the Plan's provisions
Other: Plan coverage will terminate .


Form submitted by
Name .
Phone .
Email .
Referred to BASE by (If Applicable - optional)
Name .
Phone .
Email .

Note: If you do not see a "Submit" button, you have not completed all of the required fields. Once you have completed all three sections successfully a "Submit" button will appear to the right of the "Save" button.