AffordaCare Employer Intake Form

01

Employer / Company Information

Legal entity, contact, ownership, and business details.

Agent Name * Agent Email *

Company Legal Name * DBA, if applicable Employer Street Address * City * State * ZIP Code * Is the mailing address different from the physical address?If checked, please complete the mailing address fields below. Phone Number * Fax Number, if applicable Primary Contact Person * Contact Title * Contact Email Address * Company Website Owner Name(s) * Owner Email * Authorized Signer Name * Authorized Signer Email Address * Nature of Business *

Type of Ownership / Filing Status *

Sole Proprietorship Partnership C-Corporation S-Corporation Government Other

Federal Tax ID * How long has the company been in business? *

02

Employee Eligibility & Compliance

Employee counts, COBRA, eligibility rules, and compliance setup.

Did you employ 20 or more full-time equivalent employees for at least 50% of the previous calendar year? *

Yes No

COBRA Enrollment: Do you want to offer COBRA if your future group size does not require it? *

Yes No

Do you want Marpai to be your COBRA admin if you are electing COBRA? *

Yes No

Total number of employees, including owners, partners, etc. * How many hours per week must an employee work, between 30 and 40 hours, to be considered eligible? *

Are any former employees currently on, or eligible to elect, continuation coverage / COBRA? *

Yes No

03

Plan Setup Details

Contribution, plan selection, waiting period, and prior coverage information.

04

Affiliated Companies / Multiple Locations

Common ownership, additional Tax IDs, and related locations.

Does your business have more than one physical location? *

Yes No

Does your company have other business organizations under common ownership or more than one Federal Tax ID number? *

Yes No

05

Required Documents Upload

Please upload the documents needed to complete employer intake and enrollment review.

Company registration document *

Please include one of the following:

Proof of state registration (preferred)
Secretary of State Certification
Articles of Incorporation

Business logo file *

Upload the business logo as a PNG or JPEG image.

Accepted file types: PNG, JPG, and JPEG.

06

Confirm & Submit

Confirm the information entered is accurate and complete the signature.

Review before submitting

Please confirm all employer information, plan setup details, and required documents are complete and accurate to the best of your knowledge.

Authorized Signature Name * Signature Date * Signer Email * Title *

Post Effective Date New Hires

Any new hires after the effective date will be subject to the group's selected waiting period.
It is recommended that additions are sent in at least 15 days prior to their effective date.
Late enrollments will not be permitted. All additions must be received within 30 days of the expiration of the waiting period.

I confirm the information provided in this intake form is complete and accurate, and I am authorized to submit it on behalf of the employer group.