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Employer/Group Dashboard
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Group Application
Broker Info
Select Plan
Group Info
Employer Info
Contact
Business Address
Billing
Payment
Group Contribution
Signature - Verification
Broker Information
Representative ID
*
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Select Plan
Select Plan
*
Select Plan...
Elite (Cigna, Blue Card & Emblem)
Elite (Blue Card High & Low)
NAWU Plans (Reference Based Plans)
Ancillary Plans
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Group Information
Group Name
*
Estimate number of members
*
Desired Start Date
*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
Year
2025
Group Type
*
Group Type...
Employer Group
Trade/Professional Association
General Business Association
PEO (Professional Employer Organization)
Chamber of Commerce
Franchise Association
Federal Tax ID Number (TIN/EIN)
*
*Social Security if Partnership
Group Industry
*
Select Industry.....
Accountants, Book Keeping, Payroll
Administrative Services
Agriculture, Farming and Dairy Industry
Architecture
Art, Design, Fashion, Photography
Automotive
Boating, Yachting, Marine
Chiropractic
Commercial Services
Construction Trades
Consulting
Contracting
Cosmetology and Beauty
Dental
Distributors, Short Haul
Education
Engineering
Film
Finance, Insurance & Executive Services
Fishing & Hunting
Forestry
Gas station/vehicle maintenance
Government
Health, Wellness & Sports
Industrial
Information Technology
Internet
Jewelers
Journalism, Writing and Publishing
Legal
Manufacturing
Media
Media & Entertainment
Medical
Non-Profit
Promotional & Marketing
Public Relations
Real Estate
Recreation
Religion
Restaurant, Bars & Hospitality
Retail
Scientific Services
Social Assistance
Support Services
Technical Services
Telecommunications
Travel Industry
Trucking, Moving & Commercial Drivers
Utilities
Veterinarian & Animal Related
Warehousing
Waste Management Services
Wholesale Trade
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Employer Name
Employer Industry
Number of Employees
Normal Work Week
Select Normal Work Week
35 Hours
40 Hours
Less than 30 hours per week
Vacation Policy
Select Vacation Policy
1 Weeks
2 Weeks
Other
Wage Scale
Select Wage Scale
Hourly
Salaried
Bargaining Unit
Select Bargaining Unit
All Employees
Sales
Clerical
Non-clerical
Other
Holiday Policy
Select Holiday Policy
Standard 6
President Day
Columbus Day
Religious Days
Birthday
Floating Day
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Group Contact Information
Group Contact First Name
*
Group Contact Last Name
*
Group changed Contact Title
*
Email
*
Mobile Phone Number
*
Fax
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Group Address
Street Address
Apt/Suite/Other
City
*
State
*
Choose a State
Alaska(AK)
Alabama(AL)
Arkansas(AR)
Arizona(AZ)
California(CA)
Colorado(CO)
Connecticut(CT)
District of Columbia(DC)
Delaware(DE)
Florida(FL)
Georgia(GA)
Hawaii(HI)
Iowa(IA)
Idaho(ID)
Illinois(IL)
Indiana(IN)
Kansas(KS)
Kentucky(KY)
Louisiana(LA)
Massachusetts(MA)
Maryland(MD)
Maine(ME)
Michigan(MI)
Minnesota(MN)
Missouri(MO)
Mississippi(MS)
Montana(MT)
NorthCarolina(NC)
North Dakota(ND)
Nebraska(NE)
New Hampshire(NH)
New Jersey(NJ)
New Mexico(NM)
Nevada(NV)
New York(NY)
Ohio(OH)
Oklahoma(OK)
Oregon(OR)
Pennsylvania(PA)
Rhode Island(RI)
South Carolina(SC)
South Dakota(SD)
Tennessee(TN)
Texas(TX)
Utah(UT)
Virginia(VA)
Vermont(VT)
Washington(WA)
Wisconsin(WI)
West Virginia(WV)
Wyoming(WY)
Zip Code
*
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Billing Address & Contact Information
Check this box if Employer/Group Address are the same.
First Name
*
Last Name
*
Street Address
*
Apt/Suite/Other
City
*
State
*
Choose a State
Alaska(AK)
Alabama(AL)
Arkansas(AR)
Arizona(AZ)
California(CA)
Colorado(CO)
Connecticut(CT)
District of Columbia(DC)
Delaware(DE)
Florida(FL)
Georgia(GA)
Hawaii(HI)
Iowa(IA)
Idaho(ID)
Illinois(IL)
Indiana(IN)
Kansas(KS)
Kentucky(KY)
Louisiana(LA)
Massachusetts(MA)
Maryland(MD)
Maine(ME)
Michigan(MI)
Minnesota(MN)
Missouri(MO)
Mississippi(MS)
Montana(MT)
NorthCarolina(NC)
North Dakota(ND)
Nebraska(NE)
New Hampshire(NH)
New Jersey(NJ)
New Mexico(NM)
Nevada(NV)
New York(NY)
Ohio(OH)
Oklahoma(OK)
Oregon(OR)
Pennsylvania(PA)
Rhode Island(RI)
South Carolina(SC)
South Dakota(SD)
Tennessee(TN)
Texas(TX)
Utah(UT)
Virginia(VA)
Vermont(VT)
Washington(WA)
Wisconsin(WI)
West Virginia(WV)
Wyoming(WY)
Zip Code
*
Email
*
Mobile Phone Number
*
Fax
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Payment Information
Payment Method
*
EFT/ACH
If ACH, please complete the following:
*
Routing Number
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Bank Name
Account Number
Name on Bank Account
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Group Contribution
Yes
No
Group Defined Contribution Type
Flat Dollar Amount
Percentage
Member
Member + 1
Member + Child(ren)
Family
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Signature & Verification
Verification Code
*
HQAVO
Verify Code
*
Type your full name which will be your “signature” to verify application terms and agreement:
*
Signature Date:
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