Company Setup - Planstin

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 Phone
Billing Contact Email
Billing Address
Street Address Address Line 2 City State 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.

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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 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*

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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
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. 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.
Hidden
Group Setup Fee Applied
Hidden
Group Setup Fee Waived
Name
First Last
Signature*

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