Get Pop Client Subscription Application.pdf - Agc Health Plans Nw

This guide provides clear instructions for completing the Pop Client Subscription Application online. By following these steps, you will ensure that all necessary information is accurately submitted for the Premium Only Plan.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the application and open it for editing.
2. Begin by entering the client information in Section 1. Print or type the legal name of the company sponsoring the plan in the 'Company Name' field.
3. Complete the address section by providing the street address, city, state, and ZIP code.
4. Select the organizational entity type from the provided options—options include Corporation, Sub-S Corporation, Proprietorship, Partnership, Limited Liability Company, or Not-For-Profit.
5. Enter the Federal Identification Number (Taxpayer ID) of the employer.
6. Indicate the number of eligible employees and the governed state for the plan, typically the state of the home office.
7. If applicable, list any additional affiliated entities to be covered under this plan, including their legal names.
8. Provide the contact person’s information including their title, telephone number, fax number, and email address.
9. Specify whether this is a new plan or an amendment to a previously established Section 125 Plan and include the effective dates as required.
10. Select the 3-digit plan number that corresponds with your choice, noting any specific plan year details.
11. Identify the eligible employees by checking the appropriate boxes and outlining any exclusions if necessary.
12. Detail the entry date or waiting period for new employees.
13. Select the benefits that will be included in the Premium Only Plan by checking the corresponding boxes.
14. Fill out the section on Infinisource services and employer duties as detailed in the document.
15. For the term of subscription, review the information provided regarding service effectiveness and invoice delivery options.
16. Complete the insurance agent section if applicable, providing their name, agency, contact details, and AG number.
17. Finally, provide the employer’s signature and date, which signifies understanding and authorization for communication.
18. Once all fields are completed, save your changes. You may download, print, or share the form as needed.

Complete your forms online for a seamless application process.