Step 1 of 4 0% 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?Is the primary contact also the billing contact? Yes No Billing Contact Name First Last Billing Contact PhoneBilling Contact Email Billing Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Transaction Type*If you are new to Planstin please select, "New Company Setup". If you are making a plan change, please select, "Company Change". New Company Setup Company Change What is your group number?*Enter your existing group number. Did a broker or affiliate assist in the application process?* Yes No Broker or Affiliate Name Broker or Affiliate Number Broker or Affiliate PhoneBroker or Affiliate Email Services Selection*Select the services that you would like to enroll in with Planstin. Benefits (Learn More) - $150 setup fee Basic HR Suite (Learn More) - $95 monthly Advanced HR Suite (Learn More) $195 monthly Employee Handbook (Learn More) - $400 consulting fee Section 125 Document (Learn More) - $150 document fee Retirement - 401(k) (Learn More) - $9 per employee monthly Workers Compensation (including "pay-as-you-go") Business Insurance How many employees, contractors, officers or owners do we expect to participate in your company benefit offering?*Please enter a number greater than or equal to 1.HiddenWhat benefits would you like to make available in your benefit package? Preventive HSA Copay Advanced HealthShare Standard Dental Vision Plan Other 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 to coordinate your various benefit plans. 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* 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 Setup Fee Billing Option*How would you like to pay for the setup fee? Checking Account Credit Card Card Number* Expiration Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExpiration Year*20202021202220232024202520262027202820292030Security 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. I understand each billing account will have a $10 billing fee monthly. Group Setup Fee* I authorize the setup fee of $150.00 to be charged to the account provided. The setup fee is processed immediately. 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. HiddenGroup Setup Fee Applied HiddenGroup Setup Fee Waived Name First Last Signature* Δ