Employer Sign Up Open Content Area Company Legal Name * Company Address * City * State * *Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Washington DC West Virginia Wisconsin Wyoming Zip * Contact Name * Phone * Fax Email Total Number of Eligible Employees (Please note that there is a monthly minimum charge of $30) Medical Carriers - click here to add the plan information Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Medical Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Medical Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Medical Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Medical Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Dental Carriers - click here to add the plan information Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Dental Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Dental Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Dental Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Dental Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Vision Carriers - click here to add the plan information Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Vision Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Vision Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Vision Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number Vision Carriers - click here to add an additional plan Carrier Policy # Renewal Date Coverage Level Rate (do not include 2% COBRA Admin Fee) Single EE & Spouse EE & Child(ren) Family Carrier Telephone Number Carrier Fax Number HRA Plan Year Vendor Amount Funded by Employer Single EE & Spouse EE & Child(ren) Family FSA Plan Year Vendor Waiting Period for New Hires Medical Dependent Age Maximum Full-Time Student Age Maximum Dental Dependent Age Maximum Full-Time Student Age Maximum Vision Dependent Age Maximum Full-Time Student Age Maximum Ineligible Dependents Covered Until End of Month End of Year Submit Share