Employee Benefits Group Application

1Business Information

Legal Business Name *

Federal EIN / Tax ID *

DBA / Trade Name (if different)

Date Established *

Entity Type *

Primary Business Address *

State of Organization

Mailing Address (if different)

Primary Contact Name & Title *

Phone *

Email *

HR / Benefits Admin (if different)

HR Phone

HR Email

Business Website

Locations *

Payroll Provider

Desired Effective Date *

2Business Operations

Primary Business Type *

Other / Describe

Year-Round or Seasonal? *

Months Open (if seasonal)

Operating Hours

Number of Locations *

Do Employees Receive Tips? * Tips affect disability benefit calculations

Any Employees Living Outside California?

States (if yes)

PEO / HR Platform

Point-of-Sale System

3Employee Count & EligibilityAll counts as of today

Total W-2 Employees *

Full-Time (30+ hrs/wk) *

Part-Time (<30 hrs/wk)

Seasonal / Variable

Owners / Partners *

Expected to Enroll *

Expected to Waive *

Will Owners Enroll? *

Annual Turnover Rate

Minimum Hours/Week Required for Benefits Eligibility *

20 hrs/wk 25 hrs/wk 30 hrs/wk Other:

New-Hire Waiting Period *

Primary Waiver Reason(s) Expected

Covered under spouse/partner plan Medicare / Medi-Cal COBRA / prior plan still active Cost — unwilling to pay employee share Part-time / not eligible

4Current Coverage

Is the Business Currently Offering Any Employee Benefits? *

No — new group (skip to Section 5) Yes — shopping for replacement or better pricing Yes — shopping ahead of next renewal date

Current Plan Details — one row per active line

Line of Coverage	Current Carrier	Group Policy #	Renewal Date	Monthly Premium	Employer Pays ($ or %)	Plan Type
Medical / Health
Dental
Vision
Life / AD&D
Short-Term Disability
Long-Term Disability
Other

Primary Reason for Shopping / Making a Change

Rate increase at renewal Offering for the first time Dissatisfied with carrier or network Adding new lines of coverage Admin / billing issues Other

Explain if Other

5Desired Lines of CoverageCheck all to quote

6Medical Plan Preferences

Preferred Plan Type(s) *

HMO — lower cost, requires referrals, network-only PPO — most flexibility, no referrals, higher premium EPO — network-only, no referrals needed, mid-cost HDHP + HSA — high deductible, lowest premium, HSA-eligible Open to any — show all options

Deductible Preference *

Low deductible — richer benefits, higher premium Mid-range — balance of cost and coverage High deductible — lowest premium, greater cost-share Show options across all tiers

Specific Providers or Hospitals Employees Need to Keep?

Preferred Carrier(s) — check all acceptable

Other Coverage Priorities or Needs

Any Ongoing High-Cost Specialty Medications?

No known specialty drugs Yes (carrier will ask separately)

7Employer Contribution Strategy

Most CA small group carriers require employers to contribute at least 50% of the employee-only premium. Contribution toward dependent premium is your choice — but $0 toward dependents often depresses enrollment.

Medical — % of Employee-Only Premium *

Medical — Contribution to Dependent Premium

Dental Contribution

Vision Contribution

If Fixed $ — Medical Employee Amount

If Fixed $ — Medical Dependent Amount

Approximate Monthly Budget — All Benefits Combined

Is Cost or Coverage Quality the Higher Priority? *

Cost — keep premiums as low as possible Coverage quality — best plan we can reasonably afford Balanced — show options across the full range

8Compliance & Administration

ACA Applicable Large Employer (ALE)? *

Yes — 50+ FTEs (employer mandate applies) No — under 50 FTEs (small group rules) Unsure — need help calculating

ALE status triggers ACA mandate & 1094/1095-C reporting

Section 125 Cafeteria Plan in Place? *

Yes — employee premiums deducted pre-tax No — not yet in place No — and I want to set one up

Required to allow employees to pay their share pre-tax

COBRA Administration

Administered by TPA or payroll company Handled in-house Not currently handled Under 20 EEs — Cal-COBRA may apply

California SDI Status Affects coordination with any voluntary STD plan

Workers' Comp in Place?

Yes No

9Prior Claims & Health HistoryGroups of 10+ employees

Under 10 employees: CA carriers typically use community rating — claims history not required. Groups 10–50: may be requested. Groups 51+: 24 months of experience is standard. Do not identify any individual employee by name or diagnosis below.

Any Single Claimant With Claims Over $50,000 in Prior 24 Months?

No Yes

Yes/no only — do not identify the individual

Any Employees Currently on Leave?

No Yes

Any Employees Currently on COBRA?

No Yes

Claims Experience Report from Current Carrier

Available — will attach Requested from carrier, pending Not available / new group

Additional Comments on Claims or Health Conditions (no names or diagnoses)

10Employee CensusAll eligible employees, including those who will waive

List every employee who will be offered coverage — even those planning to waive. Tobacco use affects pricing on most CA small group plans. Dependents don't need separate rows — indicate tier in the Coverage column. For large groups, attaching a payroll export is fine.

#	Last Name	First Name	Date of BirthMM/DD/YYYY	GenderM / F / X	Home ZIP	TobaccoY / N	Hrs/Wkauto-sets FT/PT	FT / PTauto	CoverageEE/EE+S/EE+C/FAM	WaivingY / N	Waiver Reason

EE = Employee only · EE+S = Employee + Spouse/Partner · EE+C = Employee + Child(ren) · FAM = Family
Have a payroll export or spreadsheet? Upload it here instead of filling the table above:

11Supporting DocumentsAll optional — upload anything you have handy

None of the items below are required to receive quotes — the completed form above is all we need to get started. That said, each document listed here unlocks something specific: better pricing accuracy, a side-by-side comparison with your current plan, or a faster turnaround. Include what you have and skip what you don't.

Current carrier invoices Recommended if replacing coverage

What it unlocks: A direct cost comparison between what you're paying now and what we can find. Without it, we can still quote — but you won't be able to see whether you're actually saving money until later in the process. 3–6 months of invoices is ideal.

Summary of Benefits & Coverage (SBC) Recommended if replacing coverage

What it unlocks: A benefits comparison — not just price. The SBC shows exactly what your current plan covers so we can make sure any new plan matches or improves on it. Your current carrier is required by law to provide this free on request.

DE-9C or payroll register Optional

What it unlocks: Carrier verification. Some carriers want to confirm employee headcount and hours before finalizing a quote. If your census in Section 10 is complete and accurate, we may not need this at all — it typically comes up later if a carrier requests it.

Claims experience report Only if you have 10+ employees

What it unlocks: Better pricing for healthy groups. If your workforce has had low claims, this report can work in your favor — carriers use it to offer experience-rated pricing that may be lower than standard community rates. Request it from your current carrier. If you can't get it, we'll work without it.

Section 125 Cafeteria Plan document Only if one is in place

What it unlocks: Confirmation of your current pre-tax setup so we don't disrupt it when switching plans. If you don't have a Section 125 plan yet, we can help you set one up — it allows employees to pay their share of premiums before taxes, which effectively reduces their cost.

Anything else Optional

Prior renewal letters, a broker-of-record letter if you're transferring from another broker, or anything else you think might be relevant. When in doubt, upload it — more context always helps.

12Additional Notes

Anything else your agent should know

Employee BenefitsGroup Application

Application received.

Employee Benefits
Group Application