IC - HR Data Companion Form

1

Name

2

Agency

3

Client Name

4

Plan Year Start Date

Date

5

Plan Year End Date

Date

6

Enrollment Start Date

Date

7

Enrollment End Date

Date

8

Client Administrators

9

How will you communicate with the carrierPlease click all that apply

Enrollment Form

Spreadsheet

EDI

10

Number of Pay Periods

11

Lines Of Coverage

Provided

Offered to All Employees

Rates the same for all Employees

How many types of this plan?

12

Please download and fill out the Census Spreadsheet available here:
Census Spreadsheet Download
(If you want to quote your employees without dependents you may skip this form)

13

Please download and fill out the Census Spreadsheet available here:
Census Spreadsheet Download

(You will upload the completed Census in the next section)

Todo

In Progress

Done

14

Census Spreadsheet UploadSupported formats: Excel, .CSV

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

15

Please verify that you are human* This field is required.