Step 1 of 3 33% Your Contact InfoYour Name First Last Your phone number*Your email address Company ACA SettingsCompany Legal Name* Company FEIN* ACA Form Contact Name*This name and phone number populates on Forms 1095-C and 1094-C as the person to contact. First Last ACA Form Contact Phone*Are you part of an Aggregated ALE group?* Yes No Per the IRS Employer Aggregation Rules, companies with a common owner or that are otherwise related under certain rules of section 414 of the Internal Revenue Code are generally combined and treated as a single employer for determining ALE status. If the combined number of full-time employees and full-time equivalent employees for the group is large enough to meet the definition of an ALE, then each employer in the group (called an ALE member) is part of an ALE and is subject to the employer shared responsibility provisions, even if separately the employer would not be an ALE.Please provide legal name, FEIN, and ACA contact name and phone number for each ALE member Medical Benefit Plan SettingsPlease answer the following questions for each medical plan offered. Do you offer ICHRA plans?* Yes No Do you have non-calendar year plans?* Yes No When do your medical plans renew?*Please specify coverage periods for each medical plan offered. Example: Medical Plan 1 renews 10/01 and Medical Plan 2 renews 01/01Please list the open enrollment period for each medical plan offered.*Example: Medical Plan 1 = 09/01 to 09/15 and Medical Plan 2 = 12/01 to 12/15Who is eligible?*Please specify who is eligible for each medical plan offered. Example: All benefits eligible employees or Medical Plan 1 = Union employees and Medical Plan 2 = Non-union employeesDo you offer COBRA coverage to employees who experience a reduction in hours?* Yes No Upon termination, is coverage provided through the end of the month?* Yes No Are your plans self-insured?* Yes No Are all Dependents entered in Account Contacts with Name, SSN, and Birth Date and are Dependents attached to appropriate Employee Benefit Plans? Yes No Please specify the waiting period for each medical plan and/or employee group*Example: Medical Plan 1 Union employees = first of the month following 30 days from hire date and Medical Plan 2 Non-union employees = first of the month following 60 days from hire dateDo your medical plans offer Minimum Essential Coverage to:* Employee Spouse Dependents Do your medical plans offer Minimum Value to:* Employee Spouse Dependents ACA Profile SettingsPlease specify the following settings for your Variable ACA ProfileVariable-hour employees not reasonably expected to average 130 service hours per month. Includes part time and seasonal employees. This profile measures employee service hours each month and calculates the ACA Status at the end of the Measurement Period.What is your first month cutoff day?*Example: If you are hired on the 14th and your first month cutoff day is the 1st, then your first initial measurement month will be the following month and start on the 1st.Select12345678910111213141516171819202122232425262728LastMeasurement Period months*The Measurement Period is the length of time that the company will monitor an employee’s hours prior to producing an average to determine if coverage should be offered.Select3456789101112Administrative Period months:*The Administrative Period is the length of the enrollment period or time that the employee has to respond to the company's offer of coverage.Select012Stability Period months*The Stability Period is the length of time that the company must allow benefits for an employee even if their average work hours reduce below the federal threshold. The Stability Period must be equal to or greater than the Measurement Period. Select6789101112Employee Self ServiceWill you allow employees to view and download their Form 1095-C from Employee Self Service?* Yes No Will you allow the electronic copy in lieu of a printed copy? Yes No Please tell us about changes to your 2020 workforce. Please select all that apply. Furloughs Lay Offs Shared Work/Reduced Hours Re-Hires None of these CommentsPlease list additional information or questions in the comment box below.