Company Setup

Step 1 of 4

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Business Name*
Name of company, DBA or sole proprietorship.
Business Tax ID*
Please enter business EIN, Tax ID or sole proprietor social security number.
Primary Contact Name*
First Last
Primary Contact Phone*
Primary Contact Email*
Is the primary contact also the billing contact?
- Yes
- No
Billing Contact Name
First Last
Billing Contact Phone
Billing Contact Email
Billing Address
Street Address Address Line 2 City State ZIP Code
Enrollment Type*
If you are new to Planstin please select, "New Enrollment". If you are making a plan change, please select, "Plan Change".
- New Enrollment
- Plan Change
What is your group number?*
Enter your existing group number.

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Did a broker assist in the application process?*
- Yes
- No
Broker Name
Broker Number
Broker Phone
Broker Email
How many employees, officers or owners do we expect to participate in your company benefit offering?*
Please enter a value greater than or equal to 1.
What benefits would you like to make available in your benefit package?*
- ASO MEC
- Preventive Basic
- Preventive Advanced
- Health Share
- Copay Dental Plan
- PPO Dental Plan
- Vision Plan
- Accident Plan
- Critical Illness Plan
Would you like to include payroll processing service?*
- Owner Only Payroll - $50 monthly
- Full Service Payroll - $100 base plus $2 per employee/contractor
- Enhanced Payroll - $150 base plus $4 per employee/contractor
- No payroll service for now.
Additional service options
I am interested in quotes or service on the following:
- Business Insurance
- Workers Compensation
- Retirement Services
- HR Information System (HRIS)

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Terms of Service*
By choosing to self-fund or level-fund your company medical plan you’re creating an employer sponsored plan under the Employment Retirement Income Security Act (“ERISA”) and the Patient Protection and Affordable Care Act (“PPACA”). Reoccurring monthly payments by credit card or bank account draft are required. Planstin may cancel or charge additional administrative fees if not on a reoccurring payment plan.
- I agree to the terms of service in allowing Planstin Inc to coordinate your various benefit plans.
ASO MEC Claims Funding Agreement*
Administration Services Only (ASO) Minimum Essential Coverage (MEC) plan provides the benefits required to satisfy the individual mandate of the ACA laws. Large groups should also consider offering a plan that meets minimum value (MVP). By selecting the ASO MEC you understand that the claims costs of the plan are not included in the monthly charges. If a claim is to arise you agree to have the cost of the claim deducted from your billing account indicated.
- I agree to ASO MEC Claim Funding Agreement
Level-Funding Claim Funds Agreement*
The Preventive plan series are level-funded plans. By electing to level-fund your claims with us you are locking in your rate for the plan year and forfeit any unearned claim funds.
- I agree to the Level-Funding Claim Funds Agreement
Name*
First Last
Title
Signature*

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Payment Method*
Our preferred method of payment is using your business checking account and there is no fee for this option. If you choose to pay using credit card, there is an additional 3% processing fee. If you choose to be invoiced there is an additional $25 fee.
- Checking/Saving
- Credit Card
- Invoice Billed
Annual Billing
By participating in annual billing you would pay the enrolled benefits in full for the year. By doing so you do not get charged a setup fee or invoice fees. Your rates also are locked in for the year provided that you do not change coverage. If you select annual billing you will get a separate email with payment instructions as an invoice.
- Yes. I would like to pay for the year in full with annual billing.
Setup Fee Billing Option*
How would you like to pay for the setup fee?
- Checking Account
- Credit Card
Card Number*
Expiration Month*
Expiration Year*
Security Code*
Cardholder Name*
Account Name*
What name is the account in? (Ex: "ABC Sample Business" or name of sole proprietor)
Routing Number*
Account Number*
Authorized Account Holder*
By typing your name below you are giving payment authorization for initial and monthly payment of enrolled plans. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Planstin Inc in writing of any changes in my account information within 15 days. This payment authorization is required for plan administration. In the case of an ACH or Credit Card Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Planstin Inc or its assigned third party may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25 charge for each attempt returned. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing so long as the transactions correspond to the terms indicated in this authorization form.
- Yes, I agree
Monthly Payment*
Enrollment of employees are to be completed after the company setup. Once completed you will receive additional instructions for each employee to enroll in benefits.
- I authorize the monthly payments of plans that are enrolled for our company.
Group Setup Fee*
- I authorize the setup fee of $150.00 to be charged to the account provided. The setup fee is processed immediately.
Invoice Fee*
- I authorize the monthly invoice fee of $25.00. Invoices are sent by email and monthly payments are due on the first (1st) of each month. If I am late I understand that there is a $25 late fee.
Credit Card Processing Fee*
- I authorize the credit card processing fee to be added to the monthly invoice. This charge is an extra 3% of the total monthly invoice of the benefits enrolled. This extra charge does not apply to the setup fee.
Group Setup Fee Applied
Group Setup Fee Waived
Name
First Last
Signature*

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Client Resources

Small Business Benefits
Large Group Benefits
Payroll & HR Services
Health Share for Individuals
Telemedicine for Individuals
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Small Group Setup
Large Group Setup
Payroll Setup

Contact Planstin

888-920-7526 (PLAN)

283 W Hilton Dr Suite 1
St George, UT 84770

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