COBRA Administration And Compliance Solutions CLIENT .
COBRA Administration and Compliance SolutionsCLIENT INFORMATION FORMCLIENT PROFILEClient Legal Name:Tax Id #Mailing Address:City:State:Zip Code:Invoices are Emailed on a Monthly BasisPlease Designate Two ContactsName:Email:Tel:Name:Email:Tel:SYSTEM/EMAIL CONTACT INFORMATIONSelect all that applyPrimary Contact:Title:Email:Tel:Other Contact:Title:Email:Tel:Other Contact:Title:Email:Tel:Other Contact:Title:Email:Tel:Other Contact:Title:Email:Tel:Broker Contact:Title:Email:Tel:Information Provided By:Signature:AllowCOBRASystemAccessAddContact toAll ClientEmailsEmailRemittanceReportReminderEmail CarrierNotificationsIf not doneby oNoYesYesYesYesNoNoNoNoDate:1
SET UP QUESTIONNAIRE & OTHER SERVICESIs Group in Open Enrollment?Yes – Date OE ends:NoIf Yes, Duplicate and fill out Plan Information Form for Prior/Current Plan Year and New Plan YearTotal Number of Benefit Eligible Employees (Please provide Census on ActiveEmployees tab of Member Gathering Spreadsheet)Total Number of Active Employees Enrolled in Benefits (Please provide Census onActive Employees tab of Member Gathering Spreadsheet)# of Active COBRA Members – List on QB Tab of Member Gathering Form# of Pending COBRA Members – List on QB Tab of Member Gathering FormWho Will Notify Carrier of COBRA Reinstatements andTerminations? – (if ABG- please make sure this service is selected on the ServiceABGClientBrokerAgreement and complete the Carrier Information Form on page 10 of this packet)State Continuation, if Applicable is Handled ByClientABGState Continuation, if Applicable – (confirm details with Carrier)Election Form RequiredAutomatic ExtensionYes*NoIf Using Divisions – Are Plans Assigned by Division?*If yes, please list divisions and plan structure on Divisions tab of Member Gathering FormAre Any Plans Bundled Together? (HRA & Medical/Medical & Dental)Yes (List Plans Below)NoFor the Qualifying Events Listed Below, When do Benefits Terminate?Divorce/Legal SeparationEnd of MonthDate of EventIneligible DependentEnd of MonthDate of EventDeath of EmployeeEnd of MonthDate of EventWill you be sending EDI Files?If Applicable, Who Will Be Sending EDI Files?YesNoVendorGroupIf Vendor, Name of Vendor:**Contact Name:Contact Email:Contact Tel#:** Please have your vendor contact our IT Department – imichael@amben.com– for file specifications and file testing2
THE MONTHLY PREMIUM RATES ARE THE CARRIER COSTS WITHOUT THE 2% COBRA ADMINISTRATION FEEALL INFORMATION MUST BE FILLED OUT IN ORDER TO SET UP THE ACCOUNTPLAN INFORMATIONMedical/Prescription Drug BenefitMedical/Prescription Drug BenefitEffective End DateEffective End DateRATE BASED ON COVERAGE LEVEL: COMPOSITERATE BASED ON COVERAGE LEVEL: COMPOSITE(Please provide rate for all tiers even if rate is the same)(Please provide rate for all tiers even if rate is the same)TIER NAME:TIER NAME:MONTHLY PREMIUM RATES:MONTHLY PREMIUM RATES:Member OnlyMember OnlyMember SpouseMember SpouseMember 1 ChildMember 1 ChildMember ChildrenMember ChildrenMember FamilyMember FamilyORORAge of Employee with Coverage Levels* (attach/submit Excelspreadsheet)Age of Employee with Coverage Levels* (attach/submit Excelspreadsheet)Age of Employee/Spouse & # of Children* (attach/submit ExcelAge of Employee/Spouse & # of Children* (attach/submit Excelspreadsheet)spreadsheet)ACA Rates*-Age of Employee/Spouse, Adult Children, # ofChildren – (attach/submit Excel spreadsheet)ACA Rates*-Age of Employee/Spouse, Adult Children, # ofChildren – (attach/submit Excel spreadsheet)*Age Determined By:*Age Determined By:Birthday – rate changes1stof the month following birthdayBirthday – rate changes 1st of the month following birthdayBirthday as of Plan Premium Start – rate changes based on ageat time of renewalBirthday as of Plan Premium Start – rate changes based on ageat time of renewalDate Termination of Coverage Becomes Effective:Date Termination of Coverage Becomes Effective:End of MonthEnd of MonthDate of Termination/Date of COBRA EventDate of Termination/Date of COBRA EventWash/Roll-31st ofWash/Roll-31st of previous month if term 1/-15previous month if term 1/-15Or 1st of next month if term 16th-31stInsured Type:FullySelfOr 1st of next month if term 16th-31stInsured Type:FullySelfDoes the Plan Offer to Convert to Individual Plan At the Endof COBRA?YesNoDoes the Plan Offer to Convert to Individual Plan At the Endof COBRA?YesNoCARRIER INFORMATION:CARRIER INFORMATION:Carrier NameCarrier NamePlan Name: (HMO, PPO)Plan Name: (HMO, PPO)Plan or Group #Plan or Group #3
THE MONTHLY PREMIUM RATES ARE THE CARRIER COSTS WITHOUT THE 2% COBRA ADMINISTRATION FEEALL INFORMATION MUST BE FILLED OUT IN ORDER TO SET UP THE ACCOUNTMedical/Prescription Drug BenefitVision BenefitEffective End DateEffective End DateRATE BASED ON COVERAGE LEVEL: COMPOSITERATE BASED ON COVERAGE LEVEL: COMPOSITE(Please provide rate for all tiers even if rate is the same)(Please provide rate for all tiers even if rate is the same)TIER NAME:TIER NAME:MONTHLY PREMIUM RATES:MONTHLY PREMIUM RATES:Member OnlyMember OnlyMember SpouseMember SpouseMember 1 ChildMember 1 ChildMember ChildrenMember ChildrenMember FamilyMember FamilyORAge of Employee with Coverage Levels* (attach/submit Excelspreadsheet)Age of Employee/Spouse & # of Children* (attach/submit ExcelDate Termination of Coverage Becomes Effective:spreadsheet)End of MonthACA Rates*-Age of Employee/Spouse, Adult Children, # ofChildren – (attach/submit Excel spreadsheet)Date of Termination/Date of COBRA Event*Age Determined By:Wash/Roll-31st of previous month if term 1/-15Or 1st of next month if term 16th-31stBirthday – rate changes1stof the month following birthdayBirthday as of Plan Premium Start – rate changes based on ageat time of renewalInsured Type:Date Termination of Coverage Becomes Effective:Does the Plan Offer to Convert to Individual Plan At the EndYesNoof COBRA?FullySelfEnd of MonthDate of Termination/Date of COBRA EventWash/Roll-31st of previous month if term 1/-15Or 1st of next month if term 16th-31stCARRIER INFORMATION:Carrier NamePlan Name: (HMO, PPO)Plan or Group #Insured Type:FullySelfDoes the Plan Offer to Convert to Individual Plan At the Endof COBRA?YesNoCARRIER INFORMATION:Carrier NamePlan Name: (HMO, PPO)Plan or Group #4
THE MONTHLY PREMIUM RATES ARE THE CARRIER COSTS WITHOUT THE 2% COBRA ADMINISTRATION FEEALL INFORMATION MUST BE FILLED OUT IN ORDER TO SET UP THE ACCOUNTDental BenefitEffective End DateDental BenefitEffective End DateRATE BASED ON COVERAGE LEVEL: COMPOSITERATE BASED ON COVERAGE LEVEL: COMPOSITE(Please provide rate for all tiers even if rate is the same)(Please provide rate for all tiers even if rate is the same)TIER NAME:TIER NAME:MONTHLY PREMIUM RATES:MONTHLY PREMIUM RATES:Member OnlyMember OnlyMember SpouseMember SpouseMember 1 ChildMember 1 ChildMember ChildrenMember ChildrenMember FamilyMember FamilyDate Termination of Coverage Becomes Effective:Date Termination of Coverage Becomes Effective:End of MonthEnd of MonthDate of Termination/Date of COBRA EventDate of Termination/Date of COBRA EventWash/Roll-31st of previous month if term 1/-15Wash/Roll-31st of previous month if term 1/-15Or 1st of next month if term 16th-31stOr 1st of next month if term 16th-31stInsured Type:FullySelfInsured Type:FullySelfDoes the Plan Offer to Convert to Individual Plan At the Endof COBRA?YesNoDoes the Plan Offer to Convert to Individual Plan At the Endof COBRA?YesNoCARRIER INFORMATION:CARRIER INFORMATION:Carrier NameCarrier NamePlan Name: (HMO, PPO)Plan Name: (HMO, PPO)Plan or Group #Plan or Group #5
THE MONTHLY PREMIUM RATES ARE THE CARRIER COSTS WITHOUT THE 2% COBRA ADMINISTRATION FEEALL INFORMATION MUST BE FILLED OUT IN ORDER TO SET UP THE ACCOUNTHealth Reimbursement Account (HRA) BenefitHealth Reimbursement Account (HRA) BenefitPlan Year Start DatePlan Year Start DatePlan Year End DatePlan Year End DateIs this HRA linked to a Health Plan?YesNoIs this HRA linked to a Health Plan?YesNoIf yes; Name of Health PlanIf yes; Name of Health PlanAre the rates bundled with the medical plan?Are the rates bundled with the medical plan?YesNoYesNoPlease note: 1st year HRA plan rates are calculated as listed below unlessnoted otherwise by EmployerPlease note: 1st year HRA plan rates are calculated as listed below unlessnoted otherwise by EmployerTotal Amt of Benefit x .73 divided by 12 monthly premiumTotal Amt of Benefit x .73 divided by 12 monthly premiumTIER NAME:TIER NAME:MONTHLY PREMIUM RATES:MONTHLY PREMIUM RATES:Individual OnlyIndividual OnlyIndividual 1Individual 1Individual FamilyIndividual FamilyFlat RateFlat RateOther(attach copy of rates)Other(attach copy of rates)Date Termination of Coverage Becomes Effective:Date Termination of Coverage Becomes Effective:End of MonthEnd of MonthDate of Termination/Date of COBRA EventDate of Termination/Date of COBRA Event15th15th or 31st (WashRoll Rule)or31st(WashRoll Rule)ADMINISTRATOR’S INFORMATION:ADMINISTRATOR’S INFORMATION:Plan AdministratorPlan AdministratorPlan NamePlan NamePlan or Group #Plan or Group #6
THE MONTHLY PREMIUM RATES ARE THE CARRIER COSTS WITHOUT THE 2% COBRA ADMINISTRATION FEEALL INFORMATION MUST BE FILLED OUT IN ORDER TO SET UP THE ACCOUNTOther BenefitHealth FSA Benefit (Cafeteria Plan Year)Plan Year Start DateDescriptionPlan Year End DateEffective End DateRATE BASED ON COVERAGE LEVEL: COMPOSITEADMINISTRATOR’S INFORMATION:(Please provide rate for all tiers even if rate is the same)Plan AdministratorTIER NAME:MONTHLY PREMIUM RATES:Plan NameMember OnlyPlan or Group #Member SpouseMember 1 ChildMember ChildrenMember FamilyORAge of Employee with Coverage Levels* (attach/submit Excelspreadsheet)Age of Employee/Spouse & # of Children* (attach/submit Excelspreadsheet)ACA Rates*-Age of Employee/Spouse, Adult Children, # ofChildren – (attach/submit Excel spreadsheet)*Age Determined By:Birthday – rate changes 1st of the month following birthdayBirthday as of Plan Premium Start – rate changes based on ageat time of renewalDate Termination of Coverage Becomes Effective:End of MonthDate of Termination/Date of COBRA EventWash/Roll-31st of previous month if term 1/-15Or 1st of next month if term 16th-31stInsured Type:FullySelfDoes the Plan Offer to Convert to Individual Plan At the Endof COBRA?YesNoCARRIER INFORMATION:Carrier NamePlan Name: (HMO, PPO)Plan or Group #7
THE MONTHLY PREMIUM RATES ARE THE CARRIER COSTS WITHOUT THE 2% COBRA ADMINISTRATION FEEALL INFORMATION MUST BE FILLED OUT IN ORDER TO SET UP THE ACCOUNTOther BenefitCOBRA Eligible Benefits Include:DescriptionEffective End Date Medical PlansRATE BASED ON COVERAGE LEVEL: COMPOSITE(Please provide rate for all tiers even if rate is the same)TIER NAME: Dental PlansMONTHLY PREMIUM RATES:Member OnlyMember SpouseMember 1 ChildMember ChildrenMember Family Vision Plans Employee Assistance Plans Flexible Spending Accounts (FSA)ORAge of Employee with Coverage Levels* (attach/submit Excelspreadsheet)Age of Employee/Spouse & # of Children* (attach/submit Excelspreadsheet) Health Reimbursement Account (HRA) Discount ProgramsMember Specific RateACA Rates*-Age of Employee/Spouse, Adult Children, # ofChildren – (attach/submit Excel spreadsheet) Disease-specific policies that provide*Age Determined By:medical treatments (e.g., cancer)Birthday – rate changes 1st of the month following birthdayBirthday as of Plan Premium Start – rate changes based on ageat time of renewal Some Wellness Programs Prescription Drug PlansDate Termination of Coverage Becomes Effective: Hearing careEnd of MonthDate of Termination/Date of COBRA EventWash/Roll-31st of previous month if term 1/-15Or 1st of next month if term 16th-31stInsured Type:FullySelf Treatment programs and clinics maintainedby the employer (except first aid careprovided free of charge to employees duringworking hours)Does the Plan Offer to Convert to Individual Plan At the EndYesNoof COBRA?CARRIER INFORMATION:Please Note: HSAs – Health SavingsCarrier NameAccounts and Dependent Care are notPlan Name: (HMO, PPO)COBRA eligible plans.Plan or Group #8
COBRA DIRECT DEPOSIT AUTHORIZATION FORMThis authorizes American Benefits Group to send credit entries (and appropriate debit and adjustment entries),electronically or by any other commercially accepted method, to the account indicated below. This authorizes thefinancial institution holding the account to post all such entries. We agree that the ACH transactions authorizedherein shall comply with all applicable U.S. Law.The company agrees to monthly verify the funds deposited agree to the monthly COBRA Remittance reportminus the monthly Refund report that is posted to the COBRA system and to notify American Benefits Groups ofany discrepancies.This authorization is to remain in effect until American Benefits Group has received written notification from anauthorized representative of the company.REQUESTADD Authorization CANCEL Authorization* CHANGE Authorization*Effective:Effective:*When cancelling or changing your account information, please note we need to receive form at least 15 days prior to the 10th ofthe month of your request.BANK ACCOUNT INFORMATIONClient nameAccount #Account typeCheckingSavingsGeneral LedgerBank routing numberAUTHORIZATIONAuthorized signaturePrint nameTitleEmailDatePlease return completed form to:American Benefits GroupPO Box 1209Northampton, Ma 01061-1209Fax: 413-584-2561 – Email: cobrasupport@amben.comDO NOT WRITE BELOW THIS LINE –ABG Use OnlyCompleted ByDate9
CARRIER INFORMATION FORMIf the Carrier Notification option is selected on the COBRA Service Agreement, American Benefits Group willact on your behalf to contact carriers of COBRA terminations, reinstatements, address & plan changes.If the service is selected, please fill out and notify carriers to authorize American Benefits to act on your behalfand allow online access to your account(s)Client Name:Benefit Type:Date:MedicalDentalVisionOtherCarrier:Date Authorization Sent to Carrier:Contact Name:Email:Tel:Benefit Type:MedicalDentalVisionOtherCarrier:Date Authorization Sent to Carrier:Contact Name:Email:Tel:Benefit Type:MedicalDentalVisionOtherCarrier:Date Authorization Sent to Carrier:Contact Name:Email:Tel:Benefit Type:MedicalDentalVisionOtherCarrier:Date Authorization Sent to Carrier:Contact Name:Email:Tel:DO NOT WRITE BELOW THIS LINE – ABG Use OnlyCarrier:Date Sent:Date Access Received:Carrier:Date Sent:Date Access Received:Carrier:Date Sent:Date Access Received:Carrier:Date Sent:Date Access Received:10
CLIENT INFORMATION FORM . CLIENT PROFILE . Client Legal Name: Tax Id # Mailing Address: City: State: Zip Code: Invoices are Emailed on a Monthly Basis Please Designate Two Contacts. Name: Email: Tel: Name: Email: Tel: Information Provided By: Signature: Date: SYSTEM/EMAIL CONTACT INFORMATION . Select all that apply . Allow COBRA System Access Add
This operator’s manual describes the Colt Cobra Revolver and includes information on its features. The Colt Cobra is a single/double action stainless steel compact revolver. Incorporates a full length, snag free, ejector shroud and interchangeable front sight on the barrel. The revolver offers excellent accuracy, balance, and controllability.File Size: 841KBPage Count: 42Explore furtherStolen Colt Custom Cobra serial correctionwww.practicalmachinist.comColt Cobra Schematic W/ Parts List Gun Parts Corp.www.gunpartscorp.comNew Colt King Cobra Target Doesn’t Work - The Firing .thefiringline.comColt King Cobra In Gun Manuals for sale eBaywww.ebay.comColt King Cobra Disassembly - YouTubewww.youtube.comRecommended to you based on what's popular Feedback
150 GTL DX Printed in Philippines Part No. 480-216-P Version A Nothingcomes close to a Cobra English Nothingcomes close to a Cobra English 2005 Cobra Electronics Corporation 6500 West Cortland Street Chicago, Illinois 60707 USA www.cobra.com Introduction Our Thanks to You Thank you for purchasing a Cobra amateur mobile radio .
Feb 27, 2017 · Cobra 29 LTD Classic 2.25 7.28 7140-0441 Two Piece Brackets 2.25 Cobra 29 LX & 29 LX BT 2.25 7.25 7140-0441 Two Piece Brackets 2.25 Cobra 29 WX NW BT 2.56 7.28 7140-0438 Two Piece Brackets 2.56 Cobra 29 WX NWST Mobile CB 2.25 7.28 7140-0441 Two Piece Brackets 2.25 Cobra
Cobra 29 LTD Classic 2.25 7.28 7140-0441 Two Piece Brackets 2.25 Cobra 29 LX & 29 LX BT 2.25 7.25 7140-0441 Two Piece Brackets 2.25 Cobra 29 WX NW BT 2.56 7.28 7140-0438 Two Piece Brackets 2.56 Cobra 29 WX NWST Mobile CB 2.25 7.28 7140-0441 Two Piece Brackets 2.25 Cobra
increased oversight by COBRA auditors, employers are advised to engage specialists in COBRA administration. By taking a proactive approach to ensuring that COBRA regulations are followed in an appropriate and timely manner, employers should be well-positioned in case of an IRS
Operator Basic Requirements Assessment (COBRA), and companies (e.g., petroleum, chemical, pipeline, and utility industries) around the world have been using COBRA during their interview process for similar console operator positions. COBRA runs on a personal computer and
Declaration of noise and vibration emission Sound * Cobra mk1 TT L P measured, r 1m dB(A) rel 20 Pa 97 96 L W guaranteed dB(A) rel 1pW 109 108 Vibration according to EN28662 Measured vibration value a m/s2 2.3 Spread in method and
Benefits Administrator Manual; and Insurance Benefits Guide. 3. 12/17/2019 2 COBRA Continuation of coverage 4 COBRA Consolidated Omnibus Budget Reconciliation Act. Effective July 1, 1986. . COBRA coverage ext
