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COBRA Setup
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Step
1
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Thank you for choosing Flyte. Let's get started!
Desired COBRA Service Start Date
*
Simply COBRA Fees
*
Fee Acknowledgement
Setup:
$50 one time
Renewal:
$100 annually
COBRA Notification:
$40.50 per notice
Carrier/Rate Change Notification:
$10.50 per notice
DOL Notice and HIPAA Certification:
$5.50 per notice
*$10 per month fee applies once a company has a pending or enrolled Qualified Beneficiary.
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Setup has begun! Who will take point on setup?
Point Person
*
First
Last
This is the person who will be our primary contact during setup.
Point Person Phone
*
Point Person Email
*
What type of contact is this? (please check multiple if applicable)
*
Implementation Only
Main
Compliance
Billing
Note: you will be able to add multiple contacts after setup has begun.
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Company Contact Information
Main Contact (if different from point person)
First
Last
Phone
Email
What type of contact is this? (please check all that apply)
Same as Implementation Point Person
Payroll
Compliance
Billing
Note: you will be able to add multiple contacts after setup has begun.
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Company Information
Legal Business Name
*
Doing Business As (if applicable)
Phone
Nature of Business
Principle NAICS Code
Federal EIN
*
Corporation Type
*
i.e. Sub S, C Corporation, Nonprofit, Sole Proprietorship, Partnership, LLC, LLP
LLC Filed As
Address
Physical Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address (if different than physical)
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please list any other participating entities/companies
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COBRA Service Specifics
Total Employee Count
*
Total Eligible Employees
*
Do you currently have any individuals on COBRA?
*
Yes
No
If yes, how many?
*
Do you currently have any individuals in Election Period?
*
Yes
No
If yes, how many?
*
What benefits would you like included?
Note:
Please complete a
Carrier Information worksheet
worksheet
for each
benefit. -
Click HERE to download Administration and Carrier Information worksheet.
Medical
Yes
Federally Mandated
Carrier Name and Contact Info
Dental
Yes
Carrier Name and Contact Info
Vision
Yes
Carrier Name and Contact Info
HRA / 105
Yes
Carrier Name and Contact Info
Health FSA
Yes
Carrier Name and Contact Info
Hearing
Yes
Carrier Name and Contact Info
Group Life (MN only)
Yes
Carrier Name and Contact Info
Supplemental Life (MN only)
Yes
Carrier Name and Contact Info
Other
Yes
Carrier Name and Contact Info
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Agent Information
Agent Name
First
Last
Agent Email
Agent Phone
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Payment
Please note that setup of your Simply COBRA service cannot begin until we have received your completed bank authorization.
Total Due
$0.00
First year and setup fee . Annual fees apply at service renewal. Flyte HCM will invoice for any applicable service fees.
Please upload completed Bank Authorization and applicable Carrier Information worksheets here.
*
Click or drag a file to this area to upload.
Click HERE to download our Bank Authorization
Click HERE to download Administration and Carrier Information worksheet.
Note: One completed worksheet is required for each group benefit you would like COBRA processed for.
Please use the box below to detail and comments or questions you may have
Please review our terms and conditions of this form.
*
Check here if you agree to these terms and conditions
Recognition Of A Compelling Need For Confidentiality. Flyte HCM LLC "Flyte" and the Client wish to contract together for Flyte to perform Employer Services. Flyte realizes that the Client has a compelling need to maintain confidentiality and further recognizes that a contract with the Client for Employer Services will place Flyte in a position of special trust and confidence with access to confidential information in coordination with fulfilling Employer Services outlined on the Quote.
Consideration. Flyte agrees to not disclose or use, in any manner, any confidential or proprietary information or materials concerning the Client or its operations, unless required to do so in order to conduct the Employer Services Flyte is hired to perform in its ordinary course of business. Furthermore, the Client agrees not to disclose any of Flyte’s Confidential Information that would be provided or obtained during the course of the Employer Services unless express permission to do so is granted by Flyte.
Effect Of Breach. The Parties realize that a breach of this Agreement would cause substantial harm to the operations, business and goodwill of The Parties.
Term and Effective Date. The term of services, as indicated on the Quote, are for one year and may be modified throughout the year as needed or as may be required by law. Flyte agrees to notify Client of any changes, either within or at the end of the term, in writing prior to changes becoming effective. Flyte and Client reserve the right to terminate the effectiveness of this application and Employer Services via written notice to the other party and within at least 30 days termination. This agreement shall not become effective until signed by an authorized representative of the Client.
Client Acknowledgment. As a representative of the Client, I hereby agree; i. to the terms of the Employer Services Quote provided by my Flyte representative and absolve Flyte of any financial or legal recourse arising from any incorrect information provided on this application. ii. That the Client will verify all Client data including legal name, Tax ID, employee data and all other employer data related to the Employer Services, throughout implementation of the Employer Services, and agree to hold Flyte harmless for any incorrect data provided by the Client. iii. Flyte representatives do not have the right to bind Flyte. iv. Additional terms and conditions may apply to the agreement as it pertains to the specific Employer Services chosen, v. that upon signature, the Employer Services listed on the Quote will become a part of this Application.
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