Follow the steps to complete the RI HealthSource Employer Confirmation Record online.

1. Click the ‘Get Form’ button to access the RI HealthSource Employer Confirmation Record and open it in your chosen editing platform.
2. Begin by filling out the employer information section, which includes the company legal name, Doing Business As (DBA) name, Employer Identification Number (EIN), and the company address including street, suite (if applicable), city, state, and zip code.
3. Provide details on the number of eligible employees and the principal or owner’s name along with their title. Include multiple contact numbers for primary and secondary contacts, specifying whether they are work, cell, or home numbers.
4. Enter the primary contact's email and specify whether an administrator can manage the account, selecting 'Yes' or 'No.' If 'Yes', provide the administrator's email and contact details.
5. Select the choice model for the health plan and fill in the required details about the medical reference plan, including the carrier name and specific plan name. Indicate if you wish to include HRA, HSA, or FSA.
6. Complete the dental reference plan section, indicating the carrier and the specific plan name. Specify the employee groups and whether the contribution is the same for all groups if applicable.
7. Indicate the medical and dental contributions for each group, specifying amounts as percentages or dollar values for different coverage types: employee only, employee + spouse, employee + dependents, family, or dependents only.
8. Fill in the effective date, annual renewal month, and open enrollment dates for your plan, ensuring to outline any documentation provided for verification.
9. Complete the section about the employer's broker of record and ensure to provide the name of the person who completed the form along with the date of completion.
10. Finally, review the employer signature box, agree to the terms stated, sign where required, and provide the date of signature.
11. Once you have filled in all sections of the form, be sure to save your changes, download a copy for your records, and consider printing or sharing it directly from your editing platform.

Complete the RI HealthSource Employer Confirmation Record online to ensure compliance and eligibility.