2007-12-12 CC Packet - Laserfiche WebLink

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fOOlr(s Dale fa 'l~'::L- ~f- - i'~-':~?i HeaIllPllllnels SaIes~_. FuUlegaIGlooP~~_ (' ~.€L_G....k"V'~" ~(rt~) _ . Address (z.a- r~Vrj"'" ~, - __ ._ COunty--AJ:-'.f K4- _"'_ Phone~$ 4 - it?1~___1> 1 ~ 3-..__ City, State. ZIP _..Ce,f\.o~L.:'-.~\.,.. I ft."'":._.. SSa].B _ FaxJ~",,~'..V2't:::~_ Contact Person.. .J..,t.,.... hA.E~~___._TD3li~,;:-< ".{A ...~ ___email__. . Is Contact Person a1 eligible employee? ..,4ES [] NO If NO, please explain:.___ ___ 1. Who are the 0WRe1S? ___ Perc&nt of O\'Io'IIershfp for eacIl owner ____. 0- Are they eligible for coverage? 0 YES)ifNO IfMO, explain _' _.0 -1 2. Is Ihis organization in any Will related 10 other colllUlies (such as a Mional corporalion) as a whoIy ~iaIIy owned subsidiary, or lfoes this organizafion own any oh!r IXIllpaNes or have wholly or partially oM\l!d subsiiaries? 0 YES::;r.mtt IrYES, please fWOvide the HealhPartners ControDed Group foRlll 3. Corporate heldtuarters location (Cily and Stale aIldlor Cotlllly): Gci'-~'\A?t^, M.A... _ _ ._._.. Do you have any other locations or sites? 0 YES,>Ia"NO If YE!$, list the. State andJor County: __ _. 4. Number 01 years in buslness,'l.?"'~ Group's Federal Tax 10 number ~ ___. _-"---___ Induslry _GdL''t'".~* . 5. TYPE OF ENTITY: 0 S Corporation 0 C Corporation 0 Sole Proprietorship [] Partnership ~on-Proflt 0 LLe (circle QOO fo /he rlglJl: C Cl'>lp<llativn Sole Proprietorship Parlner&lilll 6. On average, ImI many indivickJas did 1his Of!}8I1i:zaIion eJllIlJoy (In a1llo!;ations contlIned), vrorkilJ a m1ninum of.20 hOLn per l.eek, thrOlJ9hout the preceding calendar year (Jarury to December)? t!" (&ckldng seasona/,'lt1IflOTB(JI B(Id IIfJion e~ covered I&'IltY II ~ bafgsining ~ 7_ Curmntly, how many employees are working a rniI1imooI of 20 /lOU'S per Met? - - Some employees who do nOl wOlk a fulllWellle months may be covered under their employers plan. These employees must Ml(k II minimum of nine months in II ccfendar year. If pfOIIidlng coveraQll for these empJoyoos, the ernpIll)ler must COIJlIlele the Small Employer ConlJilluliDn Agreement Form. ConIacl your HealihPArtieis Sales Replesentative b deIaDs. In additiln :0 the above employee count, how many employees as defined abDve. will you be covering?_ .. ___o_~ a. How many enPoYees reOOo outside of MinneSl1a? _ .__ .__ (Subnit "agB and tax for each stale) 9. If you eIett coverage, will you be ufF.ring a Medical Expense Reimbursement plan? {such as an HRA cr siIdIIr IIffaII!IllDlII 0 YES 19-NO 10. Does this Olganizalion cnrrenlly have any leased employees? 0 YES t/-No If YES, please explain: _"_ .11. Does this crgarizalion currenUy have. inlend to haw, or EWer had a Professiona Employer Organization (POO) agreemenl? 0 YE~O If YEs, pleaso pro'llid~ a copy of the aareemerrt P1ease provide the name of the PEG:__.... Dale ofPEO :qeementteTminalion: ._,_ 12. Does thisorgarHzation intend to offer same gender domestic partner coverage? 0 YES ~NO If yes, please complete domestic partner agreement. PA,RTICI:'A -ION! EMPLovEE ELIGIBILITY INFOR.tMTION AI Eligible Employees Mu~t Work AT LEAST .3 z.. HoItTS Per Week Oassification(s} of Employees EllCIuded from Coverage: 0 uniOn covered by a coIIecIive bargaining agfoormnt 0 Part-time D Union not covered by a coIective bargaining egreemeot 0 Salaried o OI:her(explain}:________.______ __._______ 0 ~ Are early Retirees eligible for ooverage? ~YES 0 NO If yes, define policy .... ..<!:!!..~ 0 Waiting Period for New Employees: 0 Date of Hire OR First of the month folio.... (check one below): )2f30 da)'s 0 60 days [] 90 dItJS 0 Olhef, expIail: Total number of eligible employees: '1 Total number of e1ig ibfe empIoyeP.!'l that are applying for coverage: _3_ Total number of errpIoyeE'-S that are waNIng coverage: (p" Total number of errployees ill1eir waiting period: ______ .:r.r:..._- (applical:ion or waiwr required) Nurrber of fOlTTler employees on COBRA oontiluatlon: pt EmpIoyerConlribution: Minimum 50% of single COIlaTage, or MedIcal: _Singe FamUy Denial: _9n!t1e _Family (f applicable) - . page1~e&o7M.~. 65