Welcome - Rehn Online
|[pic] |COBRA Insurance |
| |Group Plan Premium Information |
| |(509) 534-0600 ~ (800) 872-8979 ~ cobra@ |
|Complete form for each benefit plan offered (i.e. medical, dental, vision, etc.) |
|Employer Information |
| | | |
|Plan Renewal Effective Date | |Open Enrollment Period* |
| |
|Employer / Organization Name |
| | | | | | | |
|Employer Mailing Address | |City | |State | |Zip |
| |
|Employer Contact |
| | | |
|Contact Phone | |Contact Email Address |
| We request to cancel COBRA Administration through Rehn & Associates |
|Insurance Carrier Information |
| |
|Insurance Carrier Name |
| | | | | |
|Insurance Carrier Plan Number | |Insurance Carrier Group/Policy Number | |COBRA Subgroup Number |
|Is your plan Self Insured? | Yes No |
|Is your group a member of a multi-employer trust for insurance?* | Yes No |
|* If YES, Trust/Group Name: | |
|Make Checks Payable To**: | |
| | | | | | | |
|Payment Mailing Address | |City | |State | |Zip |
| | | |
|Membership/Billing Contact Name | |Membership/Billing Contact Email Address |
| |
|* Rehn & Associates does not send open enrollment information to COBRA participants. It is the employer’s responsibility to notify COBRA participants of any plan |
|changes. Rehn & Associates will provide a list of active COBRA participants upon request. |
|** Please verify with the insurance carrier that they will invoice and accept payments from Rehn & Associates |
|Send completed form to cobra@ or Rehn & Associates, Attn: COBRA Department, PO Box 5433, Spokane, WA 99205 |
| |
| | | |
|Form Completed By | |Date |
| | | |
|Phone Number | |Email Address |
|Traditional Rate Structure |
|Specific Plan Name: | |
|Plan Type (PPO, HDHP, etc.): | |
| |
|Rate Tier Structure |Final Premium Rate |
| |Rate must include all applicable taxes, ACA & Plan fees |
| |Do not include life, disability (LTD/STD) or supplemental insurance |
| |Do not include the 2% COBRA Administration Fee |
|Employee Only |$ |
|Employee & Spouse |$ |
|Employee & Child |$ |
|Employee & Children |$ |
|Employee, Spouse & Child |$ |
|Employee, Spouse & Children |$ |
|Spouse Only |$ |
|Child Only |$ |
|Children Only |$ |
| |
|If your plan is self insured, send premiums to: | |
| |Address |
| | | | |
| |City |State |Zip |
|Portion of premium sent to carrier (if any): | | |
| |
| | | |
|Form Completed By | |Date |
| | | |
|Phone Number | |Email Address |
[pic]
|Age Banded Rate Structure |
|Specific Plan Name: | |
|Plan Type (PPO, HDHP, etc.): | |
| |
|Rate Increase to Next Tier On |Participant Birth Date 1st of the Month After Participant’s Birth Date Plan Renewal Date |
|Are the rates gender specific, based on geographic location, etc? |No Yes (complete one form for each sub category) |
| |
Participant Age |Rate* | |Spouse Age |Rate* | |Dependent 21+ Age |Rate* | |Dependent Under 21 Count |Rate* | |0-20 |$ | |0-20 |$ | |21 |$ | |1 |$ | |21 |$ | |21 |$ | |22 |$ | |2 |$ | |22 |$ | |22 |$ | |23 |$ | |3+ |$ | |23 |$ | |23 |$ | |24 |$ | | | | |24 |$ | |24 |$ | |25 |$ | | | | |25 |$ | |25 |$ | |26 |$ | | | | |26 |$ | |26 |$ | | | | | | | |27 |$ | |27 |$ | |* Rate must include all applicable taxes, ACA & Plan fees | |28 |$ | |28 |$ | | | |29 |$ | |29 |$ | |Do not include life, disability (LTD/STD) or supplemental insurance | |30 |$ | |30 |$ | | | |31 |$ | |31 |$ | |Do not include the 2% COBRA Administration Fee | |32 |$ | |32 |$ | | | |33 |$ | |33 |$ | | | |34 |$ | |34 |$ | | | |35 |$ | |35 |$ | |Form Completed By | |36 |$ | |36 |$ | | | |37 |$ | |37 |$ | | | |38 |$ | |38 |$ | |Date | |39 |$ | |39 |$ | | | |40 |$ | |40 |$ | | | |41 |$ | |41 |$ | |Phone Number | |42 |$ | |42 |$ | | | |43 |$ | |43 |$ | | | |44 |$ | |44 |$ | |Email Address | |45 |$ | |45 |$ | | | |46 |$ | |46 |$ | | | |47 |$ | |47 |$ | | | |48 |$ | |48 |$ | | | |49 |$ | |49 |$ | | | |50 |$ | |50 |$ | | | |51 |$ | |51 |$ | | | |52 |$ | |52 |$ | | | |53 |$ | |53 |$ | | | |54 |$ | |54 |$ | | | |55 |$ | |55 |$ | | | |56 |$ | |56 |$ | | | |57 |$ | |57 |$ | | | |58 |$ | |58 |$ | | | |59 |$ | |59 |$ | | | |60 |$ | |60 |$ | | | |61 |$ | |61 |$ | | | |62 |$ | |62 |$ | |[pic] | |63 |$ | |63 |$ | | | |64+ |$ | |64+ |$ | | | |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- welcome to 2nd grade printable
- your welcome vs you re welcome
- welcome letter for benefit enrollment
- welcome to relias training course
- employee benefits welcome letter template
- welcome note for new employee
- welcome to people s bank online
- new hire benefits welcome letter
- welcome letter to new employee
- new employee benefits welcome letter
- welcome to city of new haven ct
- welcome to njmcdirect