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 Approach * One-time Audit One-time Audit followed by Ongoing Verification Ongoing Verification Confirm your preferred approach for auditing/verifying dependent eligibility.

Concerns * Describe any concerns that you may have about dependent eligibility.

Employees with Dependents (Households) * Total # of employees with 1+ dependent 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 Applicable only if employees can opt-out of Medical/Rx but choose to enroll in Dental coverage.

Employees with Dependents Enrolled in Dental ONLY * If yes, total # of employees with 1+ dependent enrolled in the Dental plan ONLY.

Will dependents with Vision coverage ONLY be audited? * Yes No Applicable only if employees can opt-out of Medical/Rx but choose to enroll in Vision coverage.

Employees with Dependents Enrolled in Vision ONLY * If yes, total # of employees with 1+ dependent enrolled in the Vision plan ONLY.

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