First Name *
Last Name *
Email *
Phone
I am a(n) * Broker Consultant Administrator Attorney Employer Other
Organization Name *
Organization State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Auditing Type * One-time Audit One-time Audit followed by Ongoing Verification Ongoing Verification Confirm your preferred approach for auditing/verifying dependent eligibility.
Plan Open Enrollment Period For plan(s) to be audited.
Is eligibility currently being verified upon enrollment? Yes No Confirm if dependent eligibility is currently being verified upon enrollment.
Plan HRIS System Confirm HRIS system currently being used, if applicable.
Concerns Describe any concerns that you may have about dependent eligibility.
Goal Start Date Confirm the date in which you would like the audit/verification to begin.
Spousal Surcharge or Carve-out? Yes No Confirm yes/no if the plan(s) to be audited apply a spousal surcharge or carve-out.
Plan Funding Type Fully insured Self-insured Combination (Fully + Self-insured) Confirm if the plan(s) to be audited are fully or self-insured.
Employees with Dependents (Households) * Total # of employees with 1+ dependent enrolled in the Medical/Rx plan.
# of Dependents Total # of dependents currently enrolled in the Medical/Rx plan.
New Households per Year * Estimated # of new households enrolled per year.
# of Qualifying Life Events per Year * Estimated # of QLEs per year.
Will dependents with Dental coverage ONLY be audited? * Yes No
Employees with Dependents * If yes, total # of employees with 1+ dependent enrolled in the Dental plan ONLY.
# of Dependents Enrolled in Dental ONLY If yes, total # of dependents enrolled in the Dental plan ONLY.
Will dependents with Vision coverage ONLY be audited? * Yes No
Employees with Dependents * If yes, total # of employees with 1+ dependent enrolled in the Vision plan ONLY.
# of Dependents Enrolled in Vision ONLY If yes, total # of dependents enrolled in the Dental plan ONLY.
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